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Man  forever  will  err;  yet  an  innate  longing  desire 
Draws  the  aspiring  mind  gently  toward  the  truth. 

Goethe. 


LOCAL  ANESTHESIA 


IN 


DENTISTRY 

WITH  SPECIAL  REFERENCE  TO  THE  MUCOUS 
AND    CONDUCTIVE    METHODS 


A   CONCISE   GUIDE   FOR    DENTISTS,  ORAL    SURGEONS  AND 

STUDENTS 


By  PROFESSOR  DR.  GUIDO  FISCHER 

Director  of  the  Royal  Dental  Institute  of  the  University  of  Marburg 


SECOND    AMERICAN     FROM    THE    THIRD     GERMAN     EDITION,     THOROUGHLY 

REVISED,    WITH    ADDITIONS 


By  RICHARD  H.  RIETHMULLER,  PhD.   (Univ.  of  Penna.),   D.D.S. 

Assistant  Demonstrator  in  Operative  Dentistry,  Medico-Chirurgical  College,  Philadelphia  ;  Instructor  in  Local  Anesthesia, 
the  Post-Graduate  School  of  Dentistry  of  Philadelphia;  Member  of  Staff  of  "The  Dental  Cosmos." 


Illustrated  with  115  engravings,  mostly  colored 


LEA  &   FEBIGER 

PHILADELPHIA   AND    NEW  YORK 
1914 


Entered  according  to  the  Act  of   Congress,  in  the  year  191 4,  by 

LEA  &   FEBIGER 
in  the  office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE. 


When  the  first  edition  of  this  book  in  EngHsh  was  offered,  a  great 
deal  of  conservatism  toward  local  anesthesia  was  expected  on  the 
part  of  the  American  dental  profession.  Such  conservatism  would 
not  have  been  without  justification,  as  both  the  agents  and  the  tech- 
nique employed  in  local  anesthesia  were  decidedly  unsatisfactory, 
even  dangerous,  before  the  advent  of  novocain-suprarenin  and  the 
perfection  of  the  methods  of  injection,  as  devised  chiefly  by  Braun 
and  so  ably  adapted  to  dental  practice  by  Fischer. 

The  rapid  exhaustion  of  the  first  edition,  the  demand  for  demon- 
strations of  novocain-suprarenin  anesthesia — without  which  the  pro- 
gram of  a  dental  society  meeting  is  no  longer  considered  complete — 
the  enthusiastic  essays  appearing  periodically  in  our  dental  journals, 
the  invitation  recently  extended  to  Dr.  Fischer  by  representative 
American  dental  institutions  to  deliver  lectures  and  give  demon- 
strations of  this  specialty,  and  the  study  clubs  subsequently  formed 
here  and  there  for  the  further  promulgation  of  his  doctrines  among 
the  profession,  all  seem  to  be  convincing  proofs  that  genuine  interest 
has  been  aroused  in  local  anesthesia  with  novocain-suprarenin  for 
dental  practice.  In  fact,  it  is  not  too  much  to  say  that  this  method 
is  in  a  fair  way  to  become  routine  practice  in  America  as  surely  as  it 
has  for  some  years  been  a  faithful  standby  in  European  dental  ofhces; 
and  it  is  being  more  and  more  universally  adopted  in  general  surgery 
for  operations  in  which  a  few  years  ago  only  general  anesthesia  would 
have  been  considered  feasible. 

As  in  all  dental  operations,  uniform  and  unmarred  success  can 
reasonably  be  expected  only  when  full  consideration  is  given  to 
the   physiological    and    anatomic   premises   upon   which   the   methods 


vi  PREFACE 

advocated  are  based,  and  if  the  exacting  requirements  of  asepsis  are 
rigorously  observed  in  the  minutest  detail. 

The  present  American  edition  (the  second)  is  based  upon  a  new 
German  edition  (the  third).  In  the  revision  no  pains  were  spared  to 
condense  and  revise  the  text,  and  to  incorporate  many  changes  and 
improvements  based  upon  the  most  authoritative  knowledge  and  the 
best  and  most  practical  procedures.  The  instrumentarium  and  the 
technique  of  making  accurate  and  safe  solutions  have  been  improved 
and  simplified,  and  the  methods  and  points  of  injection  have  been 
even  more  fully  elucidated  in  text  and  pictures.  Special  attention 
has  been  accorded  the  subjects  of  isotonia,  asepsis,  and  conductive 
anesthesia,  which  latter  method  has  become  that  of  predilection  with 
all  skilled  operators.  As  far  as  it  seemed  fitting,  other  means  and 
methods  of  local  and  general  anesthesia  have  received  consideration. 

The  German  text  has  been  liberally  translated,  and  numerous 
additions  of  a  practical  nature  have  been  made.  This  has  been  done 
with  the  full  consent  of  Dr.  Fischer,  to  whom  the  editor  is  indebted 
for  many  memorable  hours  of  discussion  and  tokens  of  personal 
friendship  in  the  preparation  of  this  volume.  Grateful  acknowledg- 
ment is  made  to  Mr.  A.  F.  Tilly  for  his  aid  in  the  proof-reading; 
the  editor  has   received  untiring  assistance  from  his  wife. 

The  publishers,  Messrs.  Lea  &  Febiger,  have  again  spared  no 
effort  or  expense  in  the  technical  execution  of  this  book.  The 
profusion  of  illustrative  material,  to  which  some  notable  additions 
have  been  made,  should  prove  a  most  valuable  feature. 

R.   H.   R. 

Philadelphia,  1914. 


CONTENTS. 


PART    I. 

MODERN   LOCAL  ANESTHETICS   AND   THEIR   APPLICATIONS. 

Pain 17 

Brief  Historical  Review 21 

Conductive  Anesthesia  (Perineural,  or  Regional  Anesthesia),  22. 

Local  versus  General  Anesthesia 25 

Preliminary  Measures  in  Local  Anesthesia.      The  Operator's  Duties        ....       30 
Anamnesia,  30.    Eroticism,  33. 

Agents  for  Local  Anesthesia 35 

Physical  Methods  of  Anesthesia 35 

x/Anesthesia  by  Freezing,  35.    Anesthesia  by  Pressure,  36. 

Chemical  Methods  of  Anesthesia 37 

Chemical  Anesthetics,  37.  Solubility  in  Water,  37.  Toxicity,  38.  Cocain  and  its  Sub- 
stitutes, 38.  Toxicity  of  Cocain,  39.  Substitutes  for  Cocain,  41.  Quinin  and  Urea 
Hydrochlorid  Compounds  Contra-indicated,  43. 

Novocain  and  its  Solutions 44 

Secret  Preparations  of  Local  Anesthetics,  44.  Novocain,  44.  Systemic  Effects  after 
Absorption,  45.  Effects  of  Novocain,  45.  Opinions  Regarding  Novocain,  46.  Novocain- 
suprarenin,  47.  Suprarenin,  47.  Stability  of  Suprarenin  Solution,  48.  Action  of 
Suprarenin,  49.  Toxicity  of  Suprarenin,  49.  The  Standard  Pipette,  50.  No  Tissue 
Lesions  from  Suprarenin,  50. 

The  Injecting  Solution  of  Novocain-Suprarenin 52 

The  Injecting  Solution,  52.  Isotonia,  52.  Non-isotonic  Preparations,  53.  Addition  of 
Thymol,  54.  Temperature  of  the  Solution,  54.  Ampoules,  55.  Tablets,  57.  Sterility 
of  Tablets,  57.  The  Solution,  its  Composition  and  Preparation,  61.  Addition  of 
Calcium  Salts,  62.  Preparation  of  the  Solution,  66.  Factors  in  a  Successful  Injection, 
71.  Compound  Tablets  of  Novocain-suprarenin  and  Sodium  Chlorid  Contra-indicated, 
71.  Mixtures  of  Novocain  and  Peptones,  and  Novocain  and  Hydrogen  Dioxid  Contra- 
indicated,  71.  Braun's  Experiences  with  Novocain  and  its  Solutions,  72.  Application 
of  Local  Anesthesia  in  Surgery,  73.    Advantages  of  Local  Anesthesia  in  Surgery,  75. 

The  Instrumentarium 80 

The  Syringe,  80.  Hubs,  83.  Iridioplatinum  Needles,  84.  Stasis  Bandage,  90.  A  Modi- 
fied Instrumentarium,  91. 

Disinfection  of  the  Field  of  Operation 95 

Asepsis  in  Injecting,  95.    Disinfection  of  the  Mucosa,  95.    Effect  of  lodin,  95.    Application 
of  lodin,  96. 
Preparation  of  the  Patient  for  Local  Anesthesia 96 


viii  CONTENTS 

PART    I  I. 

INDICATIONS  FOR   LOCAL  ANESTHESIA. 

Dangers  of  Local  Anesthesia 99 

Ethyl  Chlorid,  99.  Drugs  for  Hypodermic  Injection,  100.  Local  Action  of  Novocain, 
100.  Breaking  of  the  Needle,  loi.  Idiosyncrasy,  102.  Shock  and  Collapse,  102. 
Antidotes  in  Collapse,  103.  Postoperative  Pain,  103.  Therapeutic  Measures  in  Post- 
operative Pain,  105.     Postoperative  Hemorrhage,  106. 

The  Operator's  Responsibility 107 

Anamnesis,  108.     Harmlessness  of  the  Normal  Solution,  109. 

Accidents  following  Novocain  Injections no 

Narcotic  Slumber  following  Novocain  Injection,  no.  Toxic  Action  of  Novocain,  iii. 
Hysterical  Spasms  following  Novocain  Injections,  116.  Unduly  Prolonged  Duration  of 
Local  Anesthesia,  116. 

Indications  for  Local  Anesthesia 118 

Oral  Surgery,  118.  Anesthesia  of  Pulp  and  Dentin,  119.  Pressure  Anesthesia,  120. 
Injection  Indicated  for  Anesthesia  of  the  Dentin,  122.  Quinin  as  a  Sedative  in  Cavity 
Preparation,  124.  Chloral  Hydrate  as  a  Sedative,  124.  Pulp  Extirpation  and  Root 
Canal  Treatment,  126.     Crown  and  Bridge  Work,  127.     Resume,  128. 

Anesthesia  in  the  Therapy  of  Inflammation 129 

Practical  Experiences  in  the  Oral  Cavity,  129.  Tongue,  129.  Coryza,  129.  Lacerations, 
130.  Modifying  the  Healing  Process,  130.  Examples  from  General  Pathology,  130. 
Local  Effects  of  Anesthesia,  131.  Combating  Local  Irritability,  131.  Effect  of  Seda- 
tives, 133.    Effects  of  Anesthesia,  133.     Duration  of  Painlessness,  133. 


PART    III. 

TECHNIQUE   OF   LOCAL   ANESTHESIA. 

Anatomical  Structure  of  the  Osseous  Frame  of  the  Maxilla 135 

The  Surfaces  of  the  Maxillag,  135.    The  Posterior  Surfaces  of  the  Maxillary  Bones,  141. 
The  Mandibular  Sulcus  and  the  Mandibular  or  Inferior  Dental  Foramen       .      .      .     143 

The  Minute  Structure  of  the  Alveolar  Process 148 

Structure  of  the  Osseous  Substance,  148.  Structure  of  the  Alveoli,  150.  Transverse 
Sections  of  the  Jaws,  150.  Sections  of  the  Maxilla  and  Mandible,  154.  Details  of 
Diffusion,  157. 

The  Nerve  Supply  of  the  Masticatory  Apparatus 157 

Roots  of  the  Trigeminal  Nerve,  158.  Branches  of  Distribution  of  the  Trigeminal  Nerve, 
158.  The  Maxillary  Nerve,  158.  Branches  of  Distribution  of  the  Maxillary  Nerve,  160. 
The  Mandibular  Nerve,  162.  Anastomoses,  164.  Stimuli  Referred  by  Anastomoses, 
166. 

Areas  of  Nerve  Supply  of  the  Masticatory  Apparatus 167 

Maxilla,  167.     Mandible,  172. 
The  Minute  Distribution  of  Nerves  in  the  Alveolar  Process,  Periosteum,  and  Pulp     173 
Periosteum,  173.    Pulp,  173.    Sensitivity  of  the  Dentin,  173.    Nerve  Supply  of  the  WaUs 
of  the  Bloodvessels  in  the  Pulp,  177. 


CONTENTS  ix 

The  Technique  of  Injection 178 

Mucous  Anesthesia  by  Infiltration 178 

Injection  in  the  Mucosa,  180.  Maxilla,  183.  Palatal  Injection,  186.  Mandible,  193. 
Anesthesia  in  Inflammatory  Conditions,  195.     Principles  of  Mucous  Anesthesia,  197. 

Peridental  and  Intra-osseous  Injections 197 

Peridental  Injection,  197.    Intra-osseous  Injection,  199. 

Conductive  Anesthesia 200 

Topography  of  the  Maxilla,  201.  Injection  at  the  Maxillary  Tuberosity,  203.  Infra- 
orbital Injection,  206.  Injection  at  the  Inferior  Dental  or  Mandibular  Foramen  (Man- 
dibular Injection),  208.  Topography  of  the  Inferior  Dental  or  Mandibular  Nerve,  210. 
Technique  of  Injection  for  Mandibular  Anesthesia,  219.  Anesthesia  of  the  Buccal  Nerve, 
225.     External  Injection  in  Case  of  Ankylosis  or  Infection,  225. 

Resume  of  the  Clinical  Value  of  Conductive  Anesthesia 226 

Principles  of  Conductive  Anesthesia,  228. 

Extent  of  Local  Anesthesia  in  the  Maxilla         229 

Completion  of  Anesthesia  in  the  Maxilla,  229.  Anesthesia  in  the  Region  of  the  Maxillary 
Tuberosity,  229.  Anesthesia  in  the  Region  of  the  Infra-orbital  Foramen,  230.  Mucous 
Anesthesia  in  the  Mandible,  230.    Anesthesia  by  Way  of  the  Mandibular  Foramen,  232. 

Tables  for  Injection  Anesthesia 232 

Conclusion 235 

Index 237 


LOCAL  ANESTHESIA  IN   DENTISTRY, 


PART    I. 

MODERN   LOCAL   ANESTHETICS   AND   THEIR 
APPLICATIONS. 


PAIN. 


From  time  immemorial  the  problem  of  the  prevention  of  pain  has 
engaged  the  attention  of  practitioners  of  the  healing  art,  and  among 
its  branches  surgery  especially  has  striven  to  effect  the  removal  of 
that  which  constitutes  the  most  serious  handicap  to  its  beneficent 
endeavors.  To  dentistry — which  from  a  small  scion  of  medicine 
has  developed  into  an  independent  science — is  due  the  honor  of  intro- 
ducing the  inestimable  boon  of  what  we  know  as  "general  anesthesia;" 
while  the  further  aspiration  for  the  attainment  of  the  supreme  goal, 
i.  e.,  local  anesthesia,  has  engaged  the  earnest  cooperation  of  both 
surgical  and  dental  sciences. 

In  dental  operations,  which  are  so  extremely  painful  as  compared 
with  other  operative  interventions,  the  desire  to  diminish  or  to  abolish 
the  sensibility  of  the  teeth  is  especially  justified  since  the  general 
enervation  resulting  from  modern  civilization  is  daily  increasing. 
Moreover,  dental  disease  has  been  assuming  such  alarming  propor- 
tions that  all  possible  means  of  inhibiting  this  universal  scourge 
deserve  to  be  vseriously  considered. 

Pain  is  a  phenomenon  wisely  instituted  by  Nature.  To  use  Gold- 
scheider's  words:  "Pain  makes  us  realize  that  some  external  danger 
is  threatening  which  we  may  still  avoid,  or  that  harm  has  already 


18        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

been  done  to  the  body  requiring  our  care  if  we  would  escape  more 
serious  consequences.  Pain  arises  as  a  warning  signal  whenever  we 
are  exposed  to  such  conditions  of  life  as  by  their  continued  influence 
would  involve  general  disturbances  to  health.  Pain  appears  before  or 
simultaneously  with  the  outbreak  of  disease,  warning  man  that  his 
body  is  in  a  diseased  condition  and  requires  care.  Pain  occasioned  by 
physical  or  mental  fatigue  indicates  the  necessity  for  rest  and  recrea- 
tion. Pain,  the  symptom  of  organic  disease,  imperatively  urges  the 
patient  to  nurse  the  diseased  organ.  Pain  is  the  physician's  most 
powerful  assistant,  whose  demands  the  patient  follows  in  blind  obedi- 
ence, and  who  saves  the  physician  many  a  prescription,  many  an 
advice  as  to  diet  and  conduct.  Through  pain  Nature  imposes  rest 
even  upon  the  most  strenuous ;  it  dictates  idleness  to  the  most  energetic, 
and  forces  the  most  obstinate  to  abide  by  conditions  suitable  for  the 
diseased  body. 

"Pain  is  a  harsh  but  useful  law  of  Nature.  But,  like  all  natural 
laws,  it  is  unyielding  in  its  consistency,  blind  in  its  disregard,  brutal 
and  cruel.  Pain  appears  not  only  in  the  guise  of  benevolent  warning 
but  also  in  that  of  troublesome  torment.  Even  in  incurable  disease,  in 
affections  in  which  the  realization  of  ill  health  is  useless  for  the  patient, 
inasmuch  as  no  one  can  control  the  disease,  pain  is  present,  ruthlessly 
destroying  all  enjoyment  in  life  without  offering  any  physical  advantage 
whatever  by  way  of  compensation.  In  the  most  dangerous  diseases 
pain  is  often  absent,  thus  lulling  the  patient  into  a  sense  of  security, 
only  to  appear  and  call  for  abolition  by  artificial  means  after  the 
patient  has  undergone  an  operation  in  order  to  save  his  life.  Hence  it 
is  only  proper  that  we  physicians  should  combat  our  ally.  To  wipe 
out  pain  entirely  is  an  impossibility,  and  we  cannot  and  would  not  do 
without  it,  since  pain  is  necessary  not  only  as  a  monitor  in  the  combat 
against  the  hostile  powers  of  matter  but  also  as  an  inspirer  to  ethical 
emotions.  For  it  is  chiefly  in  the  reminiscence  of  one's  own  pain, 
both  physical  and  mental,  that  love  and  active  charity  are  rooted." 

Pain  belongs  to  that  order  of  phenomena  which  are  usually  termed 
conditions  or  general  sensations,  such  as  tickling,  itching,  hunger, 
thirst,  nausea,  and  others.    They  are  all  distinguished  by  a  high  degree 


PAIN  19 

of  pleasurable  or  unpleasurable  sensation,  and  do  not  inform  us  con- 
cerning our  environment  like  the  sensory  perceptions,  but  above  all 
attract  our  attention  to  the  altered  state  of  our  own  body. 

Pain,  empirically,  can  originate  only  within  the  radius  of  the  cen- 
tripetal sensory  nerves  and  the  nerves  of  touch,  while  the  sensations 
of  other  sensory  nerves  are  perhaps  disagreeable,  but  never  really 
painful.  Sensations  of  pain  and  touch,  therefore,  are  different  degrees 
of  the  same  sensation ;  a  light  stimulus  produces  the  sensation  of  touch 
or  pressure,  while  a  stimulus  intensified  beyond  the  maximum  produces 
pain.  Pain  is  caused  by  the  increase  of  a  stimulus  beyond  a  certain 
limit,  this  stimulus  radiating  over  neighboring  nerve  plexuses,  and 
being  of  prolonged  duration  provided  the  area  acted  upon  possesses 
sufficient  sensibility.  Hence  the  intensity  and  the  duration  of  a  stimu- 
lus exert  a  decisive  influence  upon  the  character  of  an  irritation.  If 
the  action  of  a  stimulus  is  sufficiently  prolonged,  the  sum  total  of  the 
resulting  irritation  is  probably  stored  in  the  sensory  ganglionic  cells, 
leading  to  a  consummation  of  individual  stimulative  impulses  which 
produce  the  effect  of  pain,  and  at  the  same  time  a  hyperalgesic 
condition.  Inflammatory  pain  is  probably  due  to  a  hyperalgesic  con- 
dition of  the  ganglionic  cells  induced  by  the  prolonged  action  of  a 
stimulus. 

The  character  of  pain  may  vary  considerably.  According  to  Erb, 
burning  pains  may  arise  from  an  admixture  of  sense  perceptions; 
pricking  pains  from  localization  or  expansion;  throbbing  pains  from 
change  in  the  stimulative  process.  "The  intensity  of  pain  is  greatly 
dependent  upon  psychic  factors,  and  is  the  greater  the  more  we 
abandon  ourselves  to  it,  while  diversion  and  will  power  mitigate  even 
exceedingly  unpleasurable  sensations.  Kant,  for  instance,  is  said 
to  have  overcome  the  torture  of  gout  by  concentrating  his  thoughts 
upon  a  definite  subject.  At  night,  after  the  continually  changing 
impressions  of  a  day  have  ceased  to  occupy  the  mind,  pain  is  felt  all 
the  more  intensely."      (Mangold.) 

Other  factors,  such  as  education,  character,  intelligence,  race,  age, 
sex,  and  general  health,  exert  a  considerable  influence  upon  the  origin 
and  manifestation  of  painful  affections. 


20        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

The  realization  of  suffering,  in  fact,  increases  in  direct  ratio  to  the 
development  of  the  sensory  organs. 

Pain,  like  all  other  sensations,  is  one  of  the  functions  of  the  cerebral 
cortex,  in  the  "sphere  of  physical  sensations"  of  which  the  sensory 
filaments  are  supposed  to  terminate.  If  the  tract  of  fibers  radiating 
from  the  cortical  region  is  interrupted  in  the  region  between  the  pos- 
terior and  anterior  ends  of  the  thalamus  complete  anesthesia  of  the 
opposite  half  of  the  body  ensues.  The  peripheral  sensory  nerves  of 
the  brain  and  spinal  column  within  the  spinal  cord,  including  the 
gray  substance,  are  to  be  considered  as  conductors  of  painful  sensa- 
tions. The  sympathetic  nervous  system,  however,  probably  does 
not  possess  the  faculty  of  conducting  pain. 

The  end  organs  of  the  sensory  nerves  are  tuned  to  certain  forms  of 
stimuli,  and  conduct  these  farther  on  to  the  cerebral  cortex,  probably 
in  such  a  way  that  complicated  chemical  changes  are  transmitted 
from  cell  to  cell. 

Stimuli  of  different  quality,  i.  e.,  mechanical,  chemical,  thermal, 
and  electric  stimuli,  are  capable  of  producing  painful  sensations  in 
the  sensory  end  organs,  or  along  their  conducting  tracts.  A  sensation 
of  pain  originating  in  the  cerebral  cortex  is  communicated  to  the 
parts  of  the  body  lying  outside  of  the  brain  in  such  a  manner,  however, 
that  the  pain  is  not  clearly  localized  but  vaguely  circumscribed,  as  is 
frequently  observed  in  the  oral  cavity.  The  irritability  of  diseased 
tissue  is  generally  increased,  rarely  diminished.  Acute  inflammations 
in  which  the  increase  in  blood-pressure  plays  an  important  role,  tend 
specially  to  produce  rapid  and  severe  irritations  of  the  sensory  nerve 
plexuses  involved,  i.  e.,  hyperalgesia.  On  the  other  hand,  local  dis- 
turbances in  nutrition,  as,  for  instance,  loss  of  function  in  dental 
pulps  and  chronic  edemas,  may  produce  a  diminution  of  sensation, 
i.  e.,  hypalgesia. 

Besides  the  varied  distribution  of  the  sensory  nerve  plexuses,  the 
function  and  the  situation  of  an  organ  bear  an  important  relation  to 
its  irritability.  Muscles,  subcutaneous  cellular  tissue,  tendinous 
tissue,  cartilage,  and  abdominal  organs,  for  instance,  seem  to  possess 
but  very  slight  if  any  sensibility;  while  the  epidermis,  the  mucosa  of 


BRIEF  HISTORICAL  REVIEW  21 

the  oral  and  nasal  cavities,  the  urethra,  the  periosteum,  and  the  peri- 
chondrium are  highly  sensitive;  bones  and  marrow  are  less  so,  and 
the  mucosa  of  the  stomach  and  the  intestinal  canal  from  the  esophagus 
downward,  the  lung  and  the  brain  itself,  are  entirely  insensible,  as 
Gasser  has  convincingly  proved  and  every  surgeon  knows.  This,  of 
course,  refers  only  to  direct  surgical  interference  with  these  tissues, 
disturbances  in  which  are,  as  a  rule,  painfully  referred  to  adjacent 
tissues  of  greater  sensitivity. 

From  the  beginnings  of  practical  medicine  this  distribution  of 
sensitive  areas  throughout  the  body  has  been  carefully  studied,  and 
indefatigable  efforts  have  been  made  to  reduce  the  sensibility  of  the 
tissues  by  artificial  means  so  as  to  render  operative  interventions 
possible.  These  efforts  tend  to  produce  either  abolition  of  sensibility, 
i.  e.,  anesthesia,  or  at  least  inhibition  of  painful  sensation,  i.  e.,  analgesia. 
This  condition  of  insensibility  is  sometimes  brought  about  by  Nature 
itself,  when,  for  instance,  normal  irritability  of  the  sensory  nerves  is 
reduced  during  profound  sleep  or  in  sickness;  but  it  can  be  produced 
by  artificial  means,  i.  e.,  narcotics,  such  as  chloroform,  ether,  etc.; 
local  anesthetics,  such  as  cocain,  novocain,  etc.,  or  hypnosis. 


BRIEF  HISTORICAL  REVIEW. 

Among  all  peoples  and  in  all  eras  efforts  have  been  made,  more  or 
less  successfully,  to  discover  means  for  the  prevention  of  pain.  It  was, 
however,  not  so  much  local  as  general  anesthesia  which  at  first  appeared 
desirable,  and  various  agents,  especially  vegetable  extracts,  were  admin- 
istered for  that  purpose.  Narcotizing  decoctions,  such  as  the  man- 
drake root  potion,  were  frequently  given  in  order  to  produce  a  sleep- 
like state,  during  which  operative  interventions  could  be  carried  out. 

In  the  year  50  a.d.  Dioscorides  is  said  to  have  made  the  first 
attempt  to  produce  a  sort  of  anesthesia  by  pulverizing  the  Memphis 
stone,  mixing  it  with  vinegar  into  a  paste,  and  allowing  it  to  act  locally 
upon  the  skin  for  some  time  before  an  operation.  In  this  preparation 
carbonic  acid   presumably   played   some  role,   being  liberated   in   the 


22        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

mixture  of  limestone  and  vinegar,  and  producing  cold,  thereby  effecting 
a  slight  anesthesia  in  the  skin  area  thus  treated. 

In  the  Middle  Ages  local  anesthesia  seems  to  have  fallen  into 
oblivion,  for  it  was  not  until  the  end  of  the  eighteenth  century  that 
James  Moore  suggested  that  by  compressing  nerve  trunks,  or  by 
severing  them,  analgesic  areas  could  be  produced.  Owing  to  the 
numerous  anastomoses  of  nerves,  the  effect  of  Moore's  procedure 
naturally  was  but  a  limited  one,  and  the  efforts  of  the  investigators 
of  that  time  were  therefore  directed  to  perfecting  the  methods  of 
general  anesthesia. 

It  was  in  1866  that  local  anesthesia  began  to  receive  its  due  recog- 
nition. This  was  brought  about  by  comparatively  successful  attempts 
of  Richardson  to  obtain  anesthesia  of  the  skin  by  means  of  the  ether 
spray,  the  application  of  which,  in  a  limited  degree,  is  considered 
correct  practice  to  this  day.  Richardson,  who  did  pioneer  work 
also  in  the  field  of  general  anesthesia,  is  entitled  to  special  credit  in 
regard  to  local  anesthesia,  for  he  drew  attention  to  the  great  value  of 
this  method,  and  succeeded  in  interesting  the  surgeons  of  the  day  in 
his  ideas. 

About  the  seventies  of  the  last  century  local  anesthesia  lay  dor- 
mant until  it  was  awakened  into  new  life  by  the  efforts  of  Koller, 
Schleich,  Robson,  Corning,  Oberst,  and  others.  At  the  Congress  of 
Ophthalmologists  held  in  Heidelberg,  in  1884,  Koller  demonstrated 
the  remarkable  anesthetizing  power  of  cocain,  which,  after  its  action 
had  been  hurriedly  tested  by  many  authorities,  quickly  sprang  into 
general  popularity.  But  the  methods  of  application  of  this  drug  were 
not  sufficiently  tested,  and  consequently,  especially  in  anesthesia  of 
the  mucous  membrane,  fatalities  frequently  occurred  owing  to  the 
toxicity  of  cocain,  until  Schleich  and  Reclus  introduced  their  method 
of  infiltration  anesthesia  by  means  of  comparatively  very  small  cocain 
doses.  This  method  was  still  further  perfected  when  Braun  recom- 
mended the  admixture  of  extract  of  the  suprarenal  capsule  with  the 
anesthetic  solution. 

Conductive  anesthesia  (perineural  or  regional  anesthesia),  which  is 
used  so  successfully  today,  was  first  suggested   by  Halsted   in   1885. 


BRIEF  HISTORICAL  REVIEW  23 

Instead  of  injecting  cocain  in  the  vicinity  of  the  tooth  to  be  anesthet- 
ized, he  injected  it  near  the  trunk  of  the  inferior  dental  nerve.  This 
principle  of  perineural  injection  was  applied  by  Kummer  and  Pernice 
in  anesthesia  of  toes  and  fingers. 

Medullary  anesthesia,  which  also  is  very  popular  today,  and  which 
has  been  perfected  by  Bier,  was  known  as  early  as  1885  to  Corning, 
who  discovered  by  animal  experiments  that  the  lower  extremities 
became  insensible  after  anesthetization  of  the  spinal  cord  by  injection 
between  the  spinous  processes  of  the  lumbar  vertebrae. 

Many  investigators,  such  as  Schleich,  von  Mikulicz,  Braun,  Kocher, 
and  von  Eiselsberg,  who  have  materially  contributed  to  the  progress 
made  in  this  field,  have  specially  sought  to  do  away  with  the  toxic 
effects  of  cocain  on  the  heart  and  the  central  nervous  system  which 
must  be  reckoned  with,  despite  its  excellent  anesthetizing  action.  "In 
no  instance  is  it  justifiable  to  speak  of  cocain  mixtures  as  being  harm- 
less; in  their  application,  therefore,  the  greatest  care  is  needed,  as  the 
effects  of  cocain  on  the  entire  organism,  especially  the  central  nervous 
system,  must  be  realized  constantly.  I  have  collected  records  of  a 
great  many  cases  in  which  serious  sequelae  from  this  drug  were  noted, 
even  disturbances  of  the  functions  of  the  brain  in  the  form  of  sexual 
affections."     (Ritter.) 

Substitutes  were  offered,  such  as  eucain  alpha  and  beta  (Silex), 
acoin  (von  Heyden),  holocain  (Tauber),  tropacocain  (Giesel),  ortho- 
form,  nirvanin  (Einhorn  and  Heinz),  anesthesin  and  subcutin  (Ritsert), 
stovain  (Fourneau),  alypin,  novocain  (Einhorn),  and  others.  All 
these  drugs  were  supposed  to  possess  the  anesthetizing  power  of  cocain 
without  its  toxicity.  Science  and  industry  made  unceasing  efforts  to 
find  an  ideal  preparation  for  the  purpose  of  local  anesthesia.  It  was 
Braun  especially  who  tried  to  compare  the  different  cocain  substitutes 
in  regard  to  their  specific  action.  He  showed  that  anesthesia  is  a 
chemical  process,  a  combination  of  the  anesthetic  with  the  cell  elements, 
i.  e.,  the  nerves  of  the  injected  area.  Contrary  to  Schleich,  he  con- 
sidered the  physical  factors,  such  as  cooling,  difference  in  osmotic 
pressure,  and  direct  pressure  upon  the  nerves,  as  non-essential.  Above 
all,   he  emphasized   that  the  simultaneous  contraction  of  the  blood- 


24        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

vessels  in  an  injected  area  is  an  important  aid  in  the  intensity  and 
duration  of  the  anesthesia.  For  this  reason  he  advised  combining 
suprarenal  preparations  with  anesthetics,  and  this  combination  has 
now  become  absolutely  indispensable. 

Thus  the  discovery  of  the  anemizing  action  of  solutions  of  suprarenal 
extract,  which  are  marketed  under  the  names  of  adrenalin,  renoform, 
suprarenin,  etc.,  has  become  of  the  greatest  importance  for  the  further 
development  and  perfection  of  injection  anesthesia.  The  chief  property 
of  these  preparations  consists  in  their  intensifying  the  action  of  cocain 
or  its  substitutes.  When  injected  in  mixture  with  an  anesthetic  solu- 
tion they  produce  a  vigorous  contraction  of  the  bloodvessels  in  the 
injected  area;  for  this  reason  not  only  the  absorption  of  the  anesthetic 
is  retarded,  but  also  considerably  smaller  quantities  of  the  anesthetic 
mixture  produce  as  deep  an  anesthesia  as  that  afforded  by  consider- 
ably larger  doses  of  pure  cocain  or  novocain  solutions.  This  is  specially 
true  of  the  combination  of  novocain  and  suprarenin,  which  latter  is 
now  prepared  synthetically.  This  novocain-suprarenin  mixture,  while 
equally  potent,  is  less  toxic  than  the  combination  of  cocain  and  supra- 
renin, and  is  therefore  given  the  preference  in  surgical  and  dental 
operations. 

Local  anesthesia  by  injection  is  sure  to  become  soon  a  common 
practice  in  dentistry,  owing  to  the  noteworthy  work  of  propaganda 
for  its  general  adoption.  By  their  researches,  Biinte  and  Moral, 
Cieszynski,  Konrad  Cohn,  Eckstrom,  Euler,  Hiibner,  Luniatschek, 
Misch,  Moller,  Paul,  Peckert,  Port,  H.  Prinz,  Reinmoller,  Reclus, 
Ritter,  Rosenberg,  Sachse,  Schaffer-Stuckert,  H.  Schroder,  Seitz, 
Sauvez,  Thiesing,  Viau,  Walkhoff,  Williger,  Ad.  Witzel,  and  many 
others,  have  made  valuable  contributions  toward  the  perfection  of 
the  technique  and  its  adaptation  to  our  special  field,  and  it  will  be 
the  duty  of  any  historian  who  may  in  the  future  record  the  develop- 
ment of  local  anesthesia  in  dentistry  to  accord  these  men  full  credit 
for  their  efforts. 


LOCAL   VERSUS  GENERAL  ANESTHESIA  25 


LOCAL    VERSUS    GENERAL    ANESTHESIA. 

Before  taking  up  the  aims  of  modern  local  anesthesia  in  detail, 
a  few  preliminary  remarks  on  the  relationship  between  local  and 
general  anesthesia  may  be  in  place.  The  dentist,  whose  practice 
concerns  a  very  important  but  circumscribed  portion  of  the  body, 
is  vitally  interested  in  treating  and  curing  the  organs  intrusted  to  his 
care  in  such  a  manner  that  no  damage  to  the  entire  organism  will 
result  from  his  operations.  The  question  of  the  relative  toxicity  of 
local  anesthetics  as  compared  with  that  of  general  anesthetics  is  there- 
fore of  greatest  interest  to  him. 

It  was  shown  in  our  brief  historical  review  that  the  earliest  results 
in  anesthesia  were  obtained  in  the  domain  of  central  desensitization, 
i.  e.,  general  anesthesia.  The  perfection  of  surgical  methods  of  treat- 
ment was  so  closely  connected  with  efforts  to  bring  about  the  prevention 
of  pain  that  these  two  movements  have  advanced  hand  in  hand. 

In  order  to  perform  a  difficult  and  tedious  operation  with  safety, 
the  surgeon  has  always  endeavored  to  paralyze  the  nervous  centres, 
thereby  completely  eliminating  the  sensation  and  will  power  of  his 
patient;  in  other  words,  producing  general  anesthesia.  In  the  fields 
of  minor  surgery,  ophthalmology,  dentistry,  and  others,  in  which 
surgical  intervention  renders  such  an  aid  desirable,  investigators 
have  naturally  endeavored  to  evolve  methods  by  which  the  nerve 
terminals  in  a  circumscribed  area  of  innervation  could  be  paralyzed, 
and  the  surgeon  enabled  to  operate  while  the  patient  was  fully  con- 
scious, i.  e.,  under  the  influence  of  local  anesthesia.  By  local  anesthesia 
we  mean  either  those  measures  by  which  only  the  terminal  rami- 
fications of  the  nerves  in  a  definite  area  are  influenced,  as  in  mucous  or 
infiltration  anesthesia,  or  those  by  which  a  larger  nerve  trunk  is  inter- 
cepted directly  at  its  basis,  as  in  conductive  anesthesia.  In  infiltration 
anesthesia  the  nerve  terminals  are  for  a  certain  length  of  time  inca- 
pacitated from  receiving  stimuli,  while  in  conductive  anesthesia  a 
particular  nerve  trunk  is  prevented  from  conducting  impressions. 

The  progress  of  local  anesthesia  has  been  accelerated  above  all  by 


26        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

the  want  of  perfect  safety  to  the  patient's  Hfe  which  still  inheres  in 
general  anesthesia.  Even  if  the  more  accurate  method  of  so-called 
mixed  anesthesia  is  correctly  employed,  one  fatality  in  7558  cases  is 
still  to  be  expected.  At  the  Surgeons'  Congress  of  19 10  Neuber 
estimated  that  one  fatality  still  occurred  in  2953  cases  of  chloroform 
anesthesia.  These  statistics  are  considerably  swollen  by  the  very 
many  errors  that  occur  in  general  anesthesia,  and  the  frequently 
injudicious  employment  of  this  method  in  cases  in  which  local  anes- 
thesia is  clearly  indicated.  In  minor  interventions,  such  as  tooth 
extractions,  the  employment  of  general  anesthesia  has  often  brought 
about  the  patient's  subsequent  death.  General  anesthesia,  moreover, 
requires  such  preparations  as  are  considered  by  most  patients  as 
decidedly  disagreeable,  and  its  induction  is  often  followed  by  serious 
after-effects. 

Although  the  operative  measures  which  are  connected  with  the 
induction  of  local  anesthesia  may  cause  some  fear  and  anxiety,  the 
patient,  being  fully  conscious  of  all  the  steps  of  the  entire  operation, 
enjoys  the  great  advantage  of  not  being  exposed  to  any  vital  danger 
whatever,  owing  to  the  high  state  of  perfection  which  local  anesthesia 
has  reached  as  compared  with  general  anesthesia.  The  reported 
fatalities  from  local  anesthesia  have  been  due  almost  exclusively  to 
the  employment  of  cocain.  The  methods  of  local  anesthesia  as  prac- 
ticed in  interventions  in  the  eye,  mouth,  nose,  ear,  and  the  extremities, 
undoubtedly  involve  but  little  probability  of  vital  danger  to  the 
patient,  especially  if  these  methods  are  practised  by  skilled  hands. 
In  the  extremely  dangerous  operations  on  the  thyroid  gland,  which 
involve  serious  interference  with  the  cardiac  nerves,  and  which,  when 
done  under  general  anesthesia,  are  liable  to  produce  syncope  of  the 
heart,  it  has  now  generally  become  surgical  practice  to  employ  local 
anesthesia.  In  dentistry  its  application  is  demanded  all  the  more 
imperatively  as  the  very  nature  of  the  field  of  operation  in  every 
respect  indicates  local  intervention. 

A  knowledge  of  the  sensibility  and  the  nerve  supply  of  the  indi- 
vidual tissues  is  indispensable.  The  skin  and  the  mucosa,  as  well  as 
the  periosteum,  the  pericementum,  the  pulp,  and  the  dentin  are  far 


LOCAL   VERSUS  GENERAL  ANESTHESIA  27 

more  sensitive  to  pain  than  the  muscles.  By  a  careful  consideration 
of  these  conditions,  however,  a  conscientious  and  experienced  operator 
will  be  able  to  operate  painlessly  provided  the  patient  faithfully 
and  patiently  follows  his  directions.  Here  we  touch  upon  a  question 
of  great  importance  in  dental  local  anesthesia,  i.  e.,  that  of  educating 
the  patient  to  have  faith  in  the  operator.  Some  nervous  persons 
regard  the  thought  of  being  operated  upon  under  a  local  anesthetic 
while  fully  conscious  as  far  more  formidable  than  the  struggle  under 
a  general  anesthetic,  and  it  requires  calmness  and  discretion  on  the 
part  of  the  operator  to  persuade  them  to  submit  to  local  anesthesia. 
It  is  the  operator's  duty,  therefore,  to  justify  fully  the  patient's  reluc- 
tantly granted  confidence  by  doing  all  within  his  power  and  skill  to 
perform  a  perfectly  painless  operation.  If  he  fails,  the  patient  will 
lose  forever  the  self-control  which  he  has  gained  by  the  operator's 
mental  suggestion,  and  will  in  the  future  swear  by  general  anesthesia. 
In  local  anesthesia  remarkable  results  can  be  obtained  by  mental 
suggestion,  and  in  our  hospital  and  private  practice  we  have  induced 
many  a  patient  by  such  mental  influence  to  submit  to  a  local  anesthetic. 

In  regard  to  technique,  local  anesthesia  offers  the  great  advantage 
of  rendering  the  aid  of  an  assistant  unnecessary;  on  the  other  hand, 
the  presence  of  a  third  person,  an  assistant,  a  woman  attendant,  or 
any  responsible  witness,  is  practically  indispensable  for  social  and 
medicolegal  reasons.  Several  cases  of  sexual  hallucinations  following 
the  injection  of  cocain  solutions  for  extractions  have  been  reported 
in  which  the  operator  had  difficulty  in  clearing  himself  from  neglect 
of  this   necessary  precaution. 

''It  has  therefore  been  established  as  a  general  rule  that  neither 
the  physician  nor  the  dentist,  without  urgent  reasons,  should  induce 
anesthesia  when  alone,  but  that  an  assistant,  or  at  least  another  person, 
should  be  present.  The  presence  of  a  witness  is,  indeed,  imperative, 
owing  to  the  additional  fact  that  frequently  during  the  application 
of  anesthetics  hallucinations  or  dreams  occur  which  deceive  the 
patient,  and  the  operator  may  consequently  become  involved  in  a 
most  disagreeable  situation.  Especially  in  treating  patients  below 
the  age  of  twenty-one  great  care   is   necessary,   since   any  operative 


28        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

step  which  is  undertaken  without  the  guardian's  permission  may 
possibly  be  denounced  as  malpractice.  A  minor  has  no  legal  right  to 
any  serious  decision,  and  for  surgical  operations,  therefore,  even  for 
the  most  insignificant  intervention  in  the  human  body,  the  consent 
of  the  parent,  guardian,  or  legal  representative  is  necessary.  Dentists 
should  take  the  greatest  possible  care  in  this  respect  when  a  serious 
oral  operation  or  the  induction  of  anesthesia  is  involved,  and  injections 
of  a  local  anesthetic  should  never  be  made  in  minors  without  previous 
agreement.  In  such  cases  a  plea  of  professional  custom  would  hardly 
be  accepted,  the  legal  representative's  special  consent  being  always 
required."      (Ritter.) 

Local  anesthesia  offers  an  additional  and  important  advantage 
over  general  anesthesia,  inasmuch  as  local  anesthetics  can  be  very 
readily  applied  and  require  no  lengthy  preparation  either  on  the 
operator's  or  on  the  patient's  part.  This  is  an  extremely  valuable  fea- 
ture, especially  for  ambulatory  dental  practice,  in  a  big  city  as  well  as 
in  the  country,  in  the  dentist's  office  as  well  as  in  the  patient's  home. 
The  production  of  general  anesthesia  under  difficult  conditions  or  in 
unsuitable  surroundings  offers  infinitely  greater  disadvantages,  and  its 
final  success  is  incomparably  more  hazardous  than  that  which  can 
be  obtained  in  dental  operations  under  local  anesthesia  by  a  skilled 
hand  almost  at  any  time,  in  any  place,  and  in  almost  any  patient.  To 
be  sure,  the  dentist  must  have  sufficient  experience  to  cope  with  any 
difficulties  that  may  arise  in  any  case;  he  must  be  a  master  in  painless 
manipulation,  and  be  fully  proficient  in  the  technique  of  local  injec- 
tions; he  must  know  exactly  the  pharmacological  and  physiological 
effects  of  his  injecting  solution,  and,  above  all,  he  must  be  able  to 
diagnose  the  general  condition  of  each  patient  in  order  to  treat  him 
according  to  individual  requirements;  for  there  is  no  doubt  that  the 
behavior  of  the  individual  organism  in  absorbing  an  injected  solution 
must  largely  determine  the  operator's  method  of  procedure.  The 
dentist  can  inject  a  smaller  quantity  of  solution  in  greatly  anemic  or 
tubercular  patients,  and  reduce  the  dose  of  the  suprarenal  extract, 
which  is  dangerous  for  the  heart,  without  jeopardizing  the  success 
of  his  operation.     Such  patients  will  often  tolerate  only  very  super- 


LOCAL   VERSUS  GENERAL  ANESTHESIA  29 

ficial  general  anesthesia,  and  even  then  they  are  in  constant  danger, 
and  pain  is  only  partially  abolished.  The  application  of  local  anes- 
thesia in  such  cases  is  far  more  advisable,  since  it  guarantees  perfect 
success  and  invariably  meets  with  the  patient's  full  approbation;  for 
it  must  not  be  overlooked  that  with  every  successful  operation  we 
gain  friends  and  advocates  of  local  anesthesia  among  our  patients, 
who  will  aid  in  popularizing  a  method  which  is  worthy  of  becoming 
common  practice  with  all  dentists.  To  what  extent  general  surgery 
has  succeeded  in  replacing  general  by  local  anesthesia  may  be  gathered 
from  Braun's  report  (see  page  107)  to  which  we  would  draw  special 
attention. 

"The  production  of  general  anesthesia,"  Riethmliller  writes, 
"under  difficult  conditions  or  in  unsuitable  surroundings  involves 
infinite  disadvantages  and  risks,  and  its  final  success  against  such 
odds  is  altogether  too  dearly  bought  when  we  know  that  for  dental 
operations  local  novocain  anesthesia  can  be  obtained  so  satisfactorily. 
Medicolegally,  also,  the  application  of  local  anesthesia  gives  the 
operator  the  advantage.  To  cite  a  medicolegal  authority  (Kupfer) : 
'After  extensive  observations  I  do  not  hesitate  to  maintain  that 
general  anesthesia,  with  the  few  exceptions  enumerated,  is  unnecessary 
in  operations  in  the  oral  cavity,  and  that,  as  a  medicolegal  expert,  I 
should  be  unable  to  protect  an  operator  from  indictment  in  case  of 
fatal  accident  from  general  anesthesia.'  Dental  colleges  would  surely 
raise  the  efficiency  of  their  graduates,  and  more  forcibly  instil  into 
them  the  necessity  of  aseptic  methods  of  operating  and  the  impor- 
tance of  an  intimate  knowledge  of  the  anatomy  of  the  head,  by  including 
a  short  practical  course  in  local  anesthesia  in  their  curriculum.  General 
surgery  is  rapidly  adopting  local  anesthesia  for  a  great  many  major 
operations,  and  it  behooves  the  dental  profession,  whose  special  field 
by  its  very  nature  calls  for  local  intervention,  not  to  lag  behind,  but 
unhesitatingly  to  keep  abreast  of  the  foremost  modern  and  efficient 
methods  available." 


30         MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

PRELIMINARY    MEASURES    IN    LOCAL    ANESTHESIA. 
THE    OPERATOR'S    DUTIES. 

After  having  shown  that  local  anesthesia  is  not  only  a  most  desir- 
able adjunct  to  the  dentist's  operative  resources  but  a  necessary 
prerequisite  for  successful  dental  practice,  the  details  of  this  procedure 
will  be  considered.  While  elaborate  preparations  for  the  correct  admin- 
istration of  general  anesthesia  are  always  required,  the  induction  of  local 
anesthesia  necessitates  only  certain  measures,  which  we  shall  discuss 
in  the  following  paragraphs: 

Anamnesis. — ^An  accurate  anamnesis  usually  can  be  best  and 
most  tactfully  secured  in  leisurely  conversation,  by  which  the  operator 
should  inform  himself  about  the  patient's  general  physical  condition. 
Special  attention  is  to  be  devoted  to  weakly  and  anemic  persons  and 
to  patients  who  are  convalescent  from  serious  infectious  diseases, 
such  as  influenza,  also  to  physically  depressed  or  nervously  irritated 
individuals,  and  hystericals — all  of  whom  require  special  care  if  they 
are  to  undergo  any  operation.  In  such  patients  the  normal  quantity 
of  an  anesthetic  which  may  be  safely  applied  in  strong  and  healthy 
persons  is  liable  to  produce  more  or  less  serious  toxic  effects,  which, 
as  a  rule,  can  be  avoided  by  injecting  a  smaller  quantity  of  the  anes- 
thetic and  by  reducing  the  percentage  of  the  suprarenal  extract.  By 
calm  self-possession  in  asking  questions,  and  by  kindly  persuasion 
which  will  dissipate  fear,  the  operator  can  instill  in  the  patient  sufficient 
composure  and  confidence  to  enable  him  to  begin  the  operation.  The 
patient's  composure  is  of  great  importance  in  the  first  insertion  of  the 
needle,  which  is  sometimes  technically  complicated,  and  can  be  accom- 
plished only  if  the  operator  has  his  patient  under  perfect  mental  con- 
trol. Success  is  assured  as  soon  as  the  needle  is  introduced  in  the 
desired  position.  If  the  patient  feels  little  or  nothing  of  the  needle 
puncture,  he  will  quickly  take  full  confidence  in  local  anesthesia,  and 
remain  calm  during  the  rest  of  the  operation,  provided  the  operator 
is  skilful  enough  to  carry  his  measures  to  a  successful  end. 

Even  if  inevitable  pain  should  arise,  the  patient  will  be  willing 
to  bear  it  provided  the  operator  has  properly  advised  him  of  such  a 


PRELIMINARY  MEASURES  IN  LOCAL  ANESTHESIA  31 

possibility.  It  may  happen  that  deep  alveolar  strata  have  not  been 
reached  by  injection  in  the  mucosa  and  have  remained  sensitive,  as, 
for  instance,  following  fracture  of  a  root.  Or  the  operator  may 
introduce  a  retractor  or  a  scalpel  in  an  insufficiently  anesthetized 
portion  of  the  mucosa,  thereby  causing  sudden  pain.  To  avoid  such 
unpleasant  incidents,  it  is  expected  of  the  modern  anesthetist  that 
he  foresee  and  consider  all  imaginable  conditions  that  may  arise,  and 
reckon  with  all  the  factors  that  may  defeat  his  object  of  painlessness. 
Every  operator  must  be  his  own  severe  critic;  he  cannot  afford  to 
overrate  his  ability  and  experience,  and  he  should  know  perfectly  well 
how  far  he  can  trust  his  skill.  He  must  be  certain  if  he  is  technically 
able  to  produce  such  anesthesia  as  the  conditions  may  demand,  or 
whether  he  should  take  the  precaution  of  notifying  the  patient  in 
advance  of  the  possibility  of  pain.  This  does  not  necessarily  discourage 
the  patient,  rather  it  contributes  to  inspiring  confidence.  Such  a 
candid  admission,  which  is  scientifically  justified,  meets  with  the 
fuller  appreciation  the  greater  the  operator's  technical  skill  and  man- 
ipulative ease,  and  it  exemplifies  modesty,  which  unfortunately  has 
becomes  a  rare  virtue.  A  certain  class  of  practitioners  are  in  the 
habit  of  guaranteeing  their  patients  absolute  painlessness,  and  exploit 
this  fraudulent  promise  in  their  advertisements;  but  such  quackery 
cannot  be  condemned  sharply  eno'ugh  as  being  unprofessional  and 
unscientific. 

A  correct  reserve  on  the  part  of  the  operator  is  all  the  more  in 
place,  as,  beside  preventing  pain,  he  is  also  obliged  to  perform  the 
operation,  and  therefore  faces  a  specially  difficult  task.  Even  though 
the  operation  be  a  minor  one,  he  nevertheless  has  to  exhibit  great 
technical  ability,  alertness  in  observation,  presence  of  mind,  and 
determination.  Thus,  for  instance,  the  problem  of  direct  anesthesia 
of  the  dentin  still  remains  unsolved,  and  it  requires  most  delicate  and 
clever  manipulation  to  extirpate  succesvsfully  so  minute  an  organ  as 
the  dental  pulp. 

Pulse  and  respiration  must  also  be  watched  in  order  that  disa- 
greeable accidents  which  would  interfere  with  the  operation,  such  as 
dizziness,  collapse,  spasms,  etc.,  may  be  recognized  by  their  symptoms 


32         MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

and  prevented.  Experience  shows  that  such  accidents  occur  frequently 
in  patients  affected  with  heart  trouble  or  some  other  constitutional 
disease;  every  dentist  therefore  ought  to  be  able  to  make  an  examina- 
tion of  the  heart  and  lungs  by  auscultation  and  percussion,  and  this 
requirement  should  be  included  in  the  dental  curriculum. 

It  is  out  of  the  question,  of  course,  that  a  thorough  physical  exami- 
nation be  made  in  every  case;  yet  from  the  patient's  history  any 
heart  trouble  can  be  recognized,  and  if  the  symptoms  are  in  the  least 
suspicious,  complications  can  be  avoided  by  a  reduction  of  the  quantity 
and  strength  of  the  injected  solution.  In  dubious  cases,  of  course, 
the  patient's  and  the  operator's  interests  are  best  safeguarded  by 
calling  into  consultation  an  experienced  diagnostician. 

After  having  taken  into  account  the  patient's  general  health,  the 
operator  must  next  consider  the  local  condition  of  the  diseased  area, 
which  frequently  determines  the  correct  selection  of  the  method  to 
be  employed  for  the  prevention  of  pain.  In  cases  of  pericementitis  or 
putrescence,  the  insertion  of  the  needle  and  the  injection  frequently 
produce  severe  pain  in  the  mucous  membrane,  and  the  anesthetic 
effect  is  very  unsatisfactory.  Here  conductive  anesthesia  is  properly 
indicated,  as  it  is  in  all  cases  where  anatomic  or  pathologic  reasons 
specially  call  for  it.  The  question  of  efficient  asepsis  must  also 
be  considered,  since  it  is  of  the  utmost  importance  in  local  injection 
anesthesia. 

From  the  foregoing  it  appears  that  the  operator,  who  incidentally 
must  be  a  capable  anesthetist,  assumes  great  responsibilities,  since 
by  faulty  manipulation  he  may  endanger  the  health,  even  the  life,  of 
his  patient  and  may  be  held  responsible  for  any  damage  caused  by 
negligence  on  his  part.  As  the  danger  for  the  patient  increases  pro- 
portionately with  the  intricate  nature  of  the  operative  procedure,  a 
perfect  mastery  of  the  anesthetic  technique  is  imperatively  demanded 
of  the  operator.  Although  the  law  does  not  require  the  presence  of  a 
skilled  assistant  in  local  anesthesia  cases,  the  operator's  responsibility 
is  by  no  means  lessened.  Only  when  proved  beyond  doubt  that  he 
has  fulfilled  his  duty  in  every  respect  will  he  be  completely  exonerated 
in  case  of  accident. 


PRELIMINARY  MEASURES  IN  LOCAL  ANESTHESIA  33 

It  is  the  operator's  further  duty  to  keep  an  accurate  record  of  the 
patient,  the  disease  observed,  and  the  therapeutic  measures  employed. 
The  method  of  injection  apphed  and  the  quantity  of  solution  injected 
must  be  noted,  also  any  symptoms  arising  during  the  operation.  Such 
a  conscientiously  kept  record  will  prove  invaluable  in  case  of  unlooked- 
for  accident,  as  it  will  substantiate  the  fact  that  the  operator  was 
fully  realizing  his  responsibility,  and  will  influence  a  verdict  in  his 
favor. 

Eroticism. — Sexual  affections  that  may  arise  in  connection  with 
anesthesia  are  due  to  the  strong  general  action  of  the  anesthetizing 
agent  upon  the  central  nervous  system,  which  gives  rise  to  a  series 
of  lascivious  thoughts  and  conceptions  similar  to  those  produced  by 
nitrous  oxid  anesthesia.  In  female  patients  such  hallucinations  very 
frequently  affect  the  genitals,  and  in  neuropathic  and  hysterical  per- 
sons, though  they  be  fully  conscious,  persist  as  real  sensations  which 
are  wrongly  interpreted.  That  conditions  simulating  sleep  may  occur 
even  in  connection  with  local  anesthesia  the  writer  has  personally 
noted  in  one  case  of  novocain  injection.  In  relation  to  this  the  case 
published  by  Korner  should  be  cited :  A  woman  had  been  locally  anes- 
thetized with  ethyl  chlorid  for  the  purpose  of  extraction  of  a  tooth, 
and  though  she  had  remained  conscious  claimed  to  have  been  assaulted 
during  the  operation.  Owing  to  the  presence  of  several  persons  who 
had  witnessed  the  operation  from  beginning  to  end,  it  was  easy  to 
explain  this  unpleasant  incident. 

"It  is  a  fact,  known  to  physician  and  dentist  alike,  that  all 
anesthetics  may  produce  erotic  dreams.  This  is  true  not  only  of  the 
agents  employed  in  general  anesthesia  but,  according  to  published 
records  and  my  own  experience,  also  of  local  anesthetics,  especially 
cocain.  One  of  the  first  to  publish  a  comprehensive  work  on  cocain 
anesthesia  in  operations  in  the  oral  cavity  was  the  late  Professor 
Dr.  Witzel.  He  states  that  in  one  of  his  women  patients,  in  whose 
gums  he  had  injected  eight  drops  of  his  cocain  solution  (0.08  cocain), 
sexual  excitement  was  noted  Ave  minutes  after  the  extraction.  Shortly 
after  the  introduction  of  cocain  in  dentistry  I  applied  this  agent  myself 
in  subcutaneous  injecti(jns,  but  abandoned  its  use  after  experiencing 


34  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

all  kinds  of  disagreeable  accidents,  above  all  syncopes  and  severe 
hemorrhages  from  extraction  wounds  due  to  failure  of  the  blood- 
vessels to  contract  normally  after  the  injection,  also  lascivious  speeches 
and  gestures,  even  confused  narrations. 

"It  is  only  within  recent  years,  since  the  adoption  of  the  so-called 
cocain  mixtures,  that  I  have  readopted  such  injections  in  my  practice. 
But  even  in  these  cocain  mixtures,  which  generally  contain  an  ad- 
mixture of  adrenalin  (suprarenal  extract),  these  symptoms  of  sexual 
excitement  appear  in  both  male  and  female  patients,  especially  the 
latter,  and  I  should  therefore  advise  every  operator  never,  if  possible, 
to  administer  local  anesthetics  to  female  patients  in  the  absence  of 
witnesses.  In  his  recent  work  on  The  Sequelce  and  Secondary  Effects  of 
Local  Anesthetics  in  Dental  Operations,  Dr.  Dorn,  who  is  to  be  regarded 
as  an  authority  on  this  subject,  agrees  with  Lewin  that  the  after- 
effect of  cocain  anesthesia  does  not  depend  upon  the  quantity  of  the 
drug  injected,  and  that,  as  has  been  verified  by  the  writer's  own  ex- 
perience, even  very  minute  doses  suffice  to  produce  secondary  toxic 
effects.  Dorn  further  reports  that  in  women,  after  the  application  of 
cocain,  erotic  conditions  may  occur,  sometimes  even  without  any 
disturbance  of  consciousness,  and  I  can  verify  these  observations, 
which  are  very  important  for  the  case  under  consideration. 

"Another  case  reported  by  Dorn  is  interesting:  A  girl,  aged 
twenty  years,  shortly  after  an  operation  under  cocain,  lapsed  into  a 
condition  of  tremendous  excitement,  respiration  being  considerably 
accelerated,  pulse  102,  and  made  voluptuous  motions  with  her  lips, 
without  notably  reacting  upon  being  spoken  to.  After  having  remained 
in  this  condition  of  mental  distraction  and  great  excitement  for  about 
ten  minutes,  she  gradually  regained  consciousness,  and  explained  that 
she  had  dreamed  of  her  fiance. 

"How  closely  cocain  intoxication  and  hysteria  may  be  related, 
and  how  dangerous  this  combination  may  be  for  the  operator,  is 
proved  by  the  following  case  published  by  Hentze:  A  young  woman 
had  a  tooth  extracted  in  the  clinic  under  local  anesthesia.  She  showed 
symptoms  of  cocain  intoxication  and  hysterical  fits,  but  soon  recovered 
and   returned   home.      Soon   afterward   the   assistant,    who   had   been 


PHYSICAL  METHODS  OF  ANESTHESIA  35 

present  at  the  operation  and  whom  she  had  not  known  even  by  name, 
received  love  letters  from  the  woman,  which  remained  unanswered. 
Three  days  following  the  operation  the  patient  committed  suicide 
by  shooting,  after  having  written  to  the  assistant  that  she  intended 
to  take  her  life  unless  she  received  a  reply.  It  was  ascertained  after- 
ward that  the  woman  was  engaged  to  some  other  man."      (Ritter.) 

These  reports  of  specially  dramatic  cases  serve  to  emphasize 
that  the  presence  of  a  third  person,  who  may  be  called  upon  to  testify, 
constitutes  a  most  valuable  safeguard  medicolegally,  if  patients 
should  experience  sexual  affections  and  accuse  the  operator  of  immoral 
attempts.  While  such  cases  are  of  fairly  frequent  occurrence  in  con- 
nection with  general  anesthesia,  and  local  anesthesia  with  cocain, 
fortunately  only  very  few  such  incidents  have  been  observed  following 
novocain-suprarenin  injections,  which  is  another  strong  argument 
in  favor  of  this  method. 


J     AGENTS  FOR  LOCAL  ANESTHESIA. 

After  these  general  considerations,  the  question  arises  by  what 
means  a  satisfactory,  safe,  and  effective  local  anesthesia  may  be 
obtained.  There  are  a  great  number  of  anesthetics  which  have  been 
applied  in  various  ways  more  or  less  successfully,  but  few  of  these 
deserve  serious  consideration  in  view  of  the  severe  specifications 
demanded  of  an  up-to-date  anesthetic.  Like  the  narcotics,  almost  all 
anesthetics  are  poisonous  to  the  vital  human  organism,  and  their 
toxic  effects  upon  the  general  system  must  therefore  be  checked  by 
suitable  dosage  and   solution. 


^  PHYSICAL    METHODS    OF    ANESTHESIA. 

Anesthesia  by  Freezing. — The  physical  methods  of  anesthesia  by 
freezing  and  pressure,  which  were  the  earliest  practiced,  are  primarily 
localized  in  their  effects.  Anesthesia  by  freezing  is  based  on  the 
principle  of  depriving  the  tissues  of  as  much  heat  as  possible  by  the 


36  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

application  of  congealing  agents,  such  as  the  well-known  ether  spray, 
which  produces  a  condition  of  analgesia  in  the  tissues.  Owing  to  the 
great  loss  of  heat,  the  tissues  of  the  living  organism  are  changed  into  a 
solid  state.  The  tissue  fluids,  blood  and  lymph,  being  of  an  aqueous 
nature,  solidify  like  water  during  frost,  affecting  the  sensory  nerve 
endings  in  such  a  way  as  to  render  them  incapable  of  transmitting 
impressions  to  the  central  organ.  The  sense  of  touch  is  thereby  affected 
but  little  or  not  at  all,  so  that  anesthesia  by  this  means  consists  not 
so  much  in  a  deadening  of  the  entire  complex  of  senses  as  in  the  abolition 
of  the  sense  of  pain,  i.  e.,  analgesia. 

The  epidermis,  and  to  even  a  greater  extent  the  mucosa,  are  per- 
meable to  gaseous  bodies.  The  gas  which  is  developed  upon  applica- 
tion of  ethyl  chlorid  to  the  warm  surface  of  the  mucous  membrane 
penetrates  the  epithelial  retiform  interstices,  the  tissue  pores  and 
glands,  owing  to  the  high  pressure  caused  by  the  deprivation  of  the 
tissues  of  heat.  Anesthesia  of  the  affected  nerve  elements  is  thus 
rapidly  produced,  but  it  usually  wears  off  just  as  rapidly. 

Anesthesia  by  Pressure. — Besides  freezing,  compression  of  nerve 
trunks  has  long  been  employed  for  the  production  of  analgesia  of  a 
limited  degree.  By  firmly  tying  a  portion  of  the  body,  as,  for  instance, 
the  arm,  the  sensation  of  pain  can  be  notably  diminished,  yet  not 
completely  abolished.  In  dentistry  the  simple  method  of  anesthesia 
by  pressure  is  still  applied  in  obtunding  hypersensitive  dentin  or 
exposed  pulps.  The  merits  of  this  procedure  will  be  considered  in  the 
special  discussion  of  dentinal  anesthesia.     (See  page  119.) 

Schleich  adopted  the  principle  of  physical  pressure  for  the  pro- 
duction of  anesthesia  by  completely  filling  the  tissues  to  be  obtunded 
with  an  injected  fluid,  thereby  producing  infiltration,  or  artificial 
edema.  The  pressure  and  tension  obtained  in  this  way  incapacitate 
the  affected  nerve  filaments  to  convey  stimuli.  By  employing  very 
weak  cocain  solutions,  Schleich  combined  physical  and  chemical 
effects  in  his  infiltration  method.  To  a  limited  degree,  anesthesia  of 
the  mucosa  in  the  alveolar  region  is  based  also  upon  such  a  combination 
of  the  pressure  and  the  chemical  action  of  the  injected  solution;  the 
latter  factor  is,  however,  of  decisive  importance.     The  drugs  intended 


CHEMICAL  METHODS  OF  ANESTHESIA  37 

for  injection  have  now  reached  such  a  high  degree  of  perfection  in 
regard  to  chemical  action  that  this  factor  dominates  the  entire  technique 
of  dental  local  anesthesia. 


CHEMICAL    METHODS    OF    ANESTHESIA. 

Chemical  Anesthetics. — All  the  anesthetics  in  more  or  less  general 
use  today  represent  organic  chemical  combinations  which  are  applied 
upon  or  within  the  tissues  in  the  form  of  suitable,  generally  aqueous, 
solutions.  For  the  anesthetization  of  mucous  surfaces  cocain  solutions 
of  high  percentages  or  concentrated  novocain  solutions  are  employed, 
while  for  injection  into  the  connective  tissue  dilute  solutions  are 
always  indicated.  The  external  application  of  these  drugs  upon  the 
oral  mucosa  produces  a  superficial  anesthetic  effect,  because  the  lym- 
phatic fluid,  which  is  distributed  through  the  tissue,  readily  seizes  the 
salts  introduced,  dissolves  them  and  carries  them  to  deeper  strata. 
This  action  is  greatly  favored  by  the  superficial  situation  of  the  sensory 
nerve  endings  which  are  distributed  closely  under  the  epithelium. 
The  surface  tension  of  aqueous  solutions  of  alkaloidal  salts  is  con- 
siderably diminished  by  the  addition  of  infinitesimal  quantities  of 
blood  serum,  according  to  the  very  interesting  investigations  of  Traube.^ 
This  fact  was  attributed  to  the  alkaline  action  of  the  blood,  especially 
because  simultaneous  researches  upon  the  influence  of  various  salts 
upon  the  surface  tension  of  alkaloidal  salts  had  shown  that  basic  salts, 
such  as  sodium  carbonate  and  others,  reduce  that  constant  to  a  marked 
degree.  The  rapidity  as  well  as  the  duration  of  the  effect  of  mixtures 
of  novocain-hydrochlorid  with  sodium  bicarbonate  is  considerably 
greater  than  that  of  pure  novocain  salts,  as  has  been  demonstrated 
by  Gros  and  Laewen. ^ 

Solubility  in  Water. — As  the  tissue  fluids  are  of  an  aqueous  nature, 
only  aqueous  solutions  of  anesthetics  are  effective,  and  the  anes- 
thetizing   power   of    these   drugs    is   directly    proportionate    to    their 

'  Biochcmischc  Zeitschrift,  191 2,  No.  6,  p.  470. 
2  Miinch.  med.  Wochenschrift,  1910,  p.  2044. 


38  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

solubility  in  water.  For  this  reason  alkaloids  which  are  very  readily 
soluble  in  water,  such  as  cocain,  eucain,  tropacocain,  novocain,  and 
others,  yield  the  best  results,  especially  when  these  have  been  made 
into  salts  such  as  hydrochlorids,  with  appropriate  acids,  in  order  to 
increase  their  solubility  in  water. 

Toxicity. — The  toxicity  of  these  anesthetic  salts  is  reduced  to  a 
minimum  by  various  measures.  The  concentration  of  the  solution 
is  restricted  to  certain  limits,  and  the  solution  itself  reacts  in  the 
human  system  according  to  certain  fixed  laws.  If  the  patient  is  given 
a  solution  of  appreciable  strength  by  the  mouth,  a  much  too  rapid 
and  extensive  absorption  takes  place,  which  is  generally  followed  by 
severe  toxic  symptoms.  The  same  quantity,  on  the  other  hand,  is 
very  well  tolerated  subcutaneously,  and  is  generally  absorbed  without 
any  local  disturbances.  Nevertheless,  even  in  subcutaneous  appli- 
cation, the  maximal  dose,  which  varies  with  different  salts,  must  not 
be  exceeded;  for  most  anesthetics,  besides  their  action  upon  the 
nerve  endings,  produce  toxic  conditions  in  the  central  nervous  system 
by  way  of  the  circulation.  While  partly  paralyzing  the  brain  and 
its  special  centres,  they  exert  an  irritating  and  destructive  influence 
which  is  the  greater  the  larger  quantities  are  introduced  into  the 
blood.  Besides,  secondary  effects  may  occur  which  are  specific  for 
each  drug,  so  that  the  conscientious  operator  has  every  reason  to 
familiarize  himself  to  the  smallest  detail  with  the  effects  of  the  anes- 
thetic which  he  employs. 

Cocain  and  Its  Substitutes. — Of  the  innumerable  anesthetics 
offered  in  the  market,  the  following  should  be  mentioned:  Cocain  and 
its  substitutes,  i.  e.,  novocain,  eucain  alpha  and  beta,  acoin,  tropa- 
cocain, holocain,  nirvanin,  anesthesin,  orthoform,  stovain,  alypin, 
yohimbin,  and  aneson,  all  of  which  with  a  few  exceptions  have  been 
discarded  after  having  been  in  vogue  but  a  short  time.  Cocain,  being 
the  original  preparation,  has  tenaciously  held  its  own  ground  despite 
the  alarming  sequelae  which  have  frequently  been  observed  following 
its  injection.  It  possesses,  however,  so  many  serious  disadvantages, 
above  all  a  specifically  high  toxicity,  that  its  employment  is  being 
limited  more  and  more,  greatly  to  the  benefit  of  suffering  humanity.    J 


CHEMICAL  METHODS  OF  ANESTHESIA  39 

Toxicity  of  Cocain. — "Transitory  disturbances  in  brain  function, 
chiefly  conditions  of  excitement,  occur  in  certain  patients  either  very 
soon  or  as  late  as  two  hours  after  the  introduction  of  cocain.  Some 
patients  chatter  with  trembhng  voice,  or  exhibit  symptoms  simulating 
intoxication.  Others  talk  confusedly,  and  show  other  symptoms  of 
mental  derangement  and  incoherence.  They  also  experience  hallu- 
cinations affecting  the  senses.  The  excitement  sometimes  is  aggra- 
vated to  the  highest  degree.  Fits  of  fury  and  delirium  lasting  for 
days,  combined  with  hallucinations,  mania  of  persecution,  etc.,  have 
frequently  been  observed.  The  delirious  attacks  may  also  occur  inter- 
mittently. In  one  instance,  a  woman  jumped  up  from  the  operating 
chair  in  a  delirious  fit,  drank  water,  and,  upon  reaching  home  and 
retiring  to  her  bedroom,  had  another  spasm,  though  afterward  she 
could  not  recollect  the  incident.  During  the  stage  of  excitement  in 
another  woman,  strongly  erotic  symptoms  were  observed.  The  excite- 
ment sometimes  alternates  with  depression,  which  assumes  the  form 
of  pronounced  melancholia  associated  with  delirium  of  persecution, 
or  of  profound  apathy  such  as  is  generally  observed  after  excessive 
excitement."      (Lewin.) 

"It  must  be  kept  in  mind  that  the  mucous  membranes,  owing  to 
their  great  vascularity,  absorb  the  alkaloid  more  rapidly  than  any 
other  tissues,  especially  when  the  former  are  inflamed.  Generally  it 
may  be  said  that  adults  can  tolerate  without  untoward  effects  up  to 
5  centigrams  of  a  i  or  2  per  cent,  solution.  In  dental  operations, 
however,  never  more  than  3  centigrams  should  be  injected. 

"Cocain  intoxication  is  either  acute  or  chronic.  As  a  rule,  the 
first  symptoms  of  an  acute  intoxication  appear  within  ten  or  fifteen 
minutes  after  the  injection,  sometimes,  however,  not  until  half  an 
hour  or  three-quarters  of  an  hour  afterward.  These  symptoms  are 
the  following:  Precordial  depression,  closely  resembling  the  pain  in 
pulmonary  and  cardiac  oppression,  very  thin  and  rapid  pulse,  pallor 
of  the  face,  coldness  of  the  extremities,  abundant  perspiration,  high 
temperature  which  may  rise  to  40°  C,  irregular  respiration,  disturb- 
ance of  the  digestive  tract  in  the  form  of  bilious  vomiting  sometimes 
associated  wnth  diarrhea,  diminished  urination  and  anuria,  which  in 


40  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

some  cases  was  observed  from  twenty-four  to  forty-eight  hours  after 
injection.  The  psychic  disturbances  are  of  a  most  pronounced  char- 
acter, and  manifest  themselves  in  the  form  of  excitement  or  garrulous- 
ness;  sometimes  the  patient  sheds  tears,  or  exhibits  great  anger  or 
fury.  The  tactile  sense  is  impaired  especially  in  the  hands,  a  prickling 
sensation  sometimes  being  noticed.  Cases  of  cramps,  or  symptomatic 
cocain  epilepsy,  have  been  observed,  followed  by  a  condition  of  motor 
and  sensory  paralysis  lasting  several  days.  Hysterical  attacks  have 
also  been  noted.  Cases  of  death  from  cocain  intoxication  have  occurred 
suddenly,  in  some  cases  two  minutes  after  the  employment  of  this 
alkaloid,  in  others  within  from  half  an  hour  to  five  hours.  While  the 
untoward  after-effects  are  not  often  fatal,  nevertheless  the  disagreeable 
secondary  symptoms  last  several  hours,  sometimes  several  days.  Post- 
mortem examinations  have  revealed  acute  congestion  of  the  lungs. 
Sometimes  numerous  small  infarcts,  also  edema  of  the  lungs,  inflam- 
mation of  the  cardiac  muscle  and  the  dura  mater,  have  been  observed, 
although  the  last  symptom  is  not  quite  certain."     (Brouardel.) 

By  a  long  series  of  carefully  conducted  experiments  Sikenberg^  has 
proved,  contrary  to  recent  teachings,  that  adrenalin  injected  simul- 
taneously with  or  after  cocain  does  not  reduce  the  toxic  effect  of  the 
alkaloid.  Equal  doses  of  cocain  with  or  without  adrenalin  had  the 
same  effect,  the  lethal  dose  also  being  the  same.  The  anesthetic  effect 
of  cocain  is  by  no  means  intensified  by  the  addition  of  adrenalin,  and 
the  same  quantity  of  cocain  is  required  no  matter  whether  adrenalin 
is  added  or  not. 

The  limit  of  concentration  of  a  non-toxic  cocain  solution  cannot 
be  accurately  determined.  Cases  have  been  observed  in  which  more 
than  2  grams  of  cocain  were  tolerated  without  serious  sequelae,  while 
very  low  doses  of  i  cgm.  have  proved  fatal.  In  regard  to  toxicity,  it  is 
essential  to  note  whether  strong  or  weak  doses  of  solution  are  employed, 
also  whether  the  drug  is  applied  to  the  mucosa  or  subcutaneously. 
But  even  in  subcutaneous  injection  the  alkaloid  may  accidentally 
enter  a  vessel  directly  and  reach  the  circulation,  so  that  a  large  quan- 
tity of  the  poison  is  conveyed  to  the  brain  in  a  relatively  short  time. 

1  Archiv  f.  klinische  Chirurgie,  vol.  Ixxvii,  No.  2. 


CHEMICAL  METHODS  OF  ANESTHESIA  41 

The  absorption  of  the  solution  takes  place  much  more  rapidly  in  highly 
vascular  tissue,  such  as  the  oral  mucosa,  the  periosteum,  etc.  Cases  of 
cocain  intoxication  after  minimal  doses  must  be  attributed  to  idio- 
syncrasies. 

Cocain  is  a  pronounced  protoplasmic  poison.  It  immediately 
retards  the  ameboid  movements  of  certain  cells,  and  inhibits  diapedesis 
of  the  leukocytes.  Cocain  furthermore  acts  as  a  specific  toxin  upon 
the  nerves,  kidneys,  and  heart;  diseases  of  these  organs,  therefore, 
constitute  a  contra-indication  to  this  drug.  It  is  also  contra-indicated 
in  anemia,  chlorosis,  neurasthenia,  nephritis,  heart  disease,  physical 
debility  of  old  age  and  convalescence. 

It  was  only  natural  that,  after  these  numerous  unfavorable  experi- 
ences with  cocain  and  its  solutions,  the  writer  joined  such  investigators 
of  note  as  Braun,  and  others,  in  a  thorough  examination  of  the  sub- 
stitutes for  cocain.  Of  the  cocain  mixtures  which  are  still  in  use, 
eusemin,  for  instance,  continues  to  enjoy  great  popularity.  In  a 
prospectus  eusemin  is  called  the  "ideal  local  anesthetic,  first,  because 
of  its  sterility;  second,  because  of  its  non-toxicity ;  third,  because  of 
its  effect  as  proved  by  experiment  and  practice."  Regarding  the 
second  point  we  must  protest,  for  at  present  there  exists  no  entirely 
non-toxic  local  anesthetic,  least  of  all  should  any  solution  that  contains 
cocain  be  represented  as  non-toxic. 

Moreover,  the  preparations  marketed  in  ampoules  are  somewhat 
untrustworthy,  according  to  recent  opinions,  because  their  stability 
is  a  limited  one.  For  this  reason,  freshly  made  solutions  are  absolutely 
preferable  to  all  stock  preparations.  At  any  rate,  all  cocain  prepa- 
rations should  be  shunned,  no  matter  how  carefully  compounded. 

Substitutes  for  Cocain. — After  an  experience  with  injection  anes- 
thesia extending  over  ten  years,  we  feel  justified  in  making  a  statement 
which  characterizes  the  present  status  of  the  question  of  solutions. 
Cocain,  even  in  infinitesimal  doses,  may  have  toxic  secondary  effects, 
as  Biberfeld,  Lewin,  Dorn,  and  Ritter  have  confirmed,  and  eusemin 
is  no  exception  to  this  rule,  as  we  have  ascertained  by  experiment. 
Like  Lewin  we  must  assume  that  "the  after-effect  of  cocain  anesthesia 
does  not  depend    upon    the  strength    of  the  dose  applied,"    but    the 


42  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

patient's  physical  and  mental  condition  plays  an  important  role.  This 
latter  factor  may  be  so  preeminent  that  even  an  ordinary  dose  of 
novocain,  although  seven  times  less  toxic  than  cocain,  may  produce 
slight  toxic  symptoms,  as  has  been  proved  in  several  reported  cases. 

That  novocain,  on  the  other  hand,  is  a  complete  substitute  for 
cocain  has  initially  been  affirmed  by  Braun.  We  can  but  fully  endorse 
his  excellent  discussion  of  this  subject,  after  having  employed  novo- 
cain to  the  fullest  extent  in  dental  practice,  and  do  not  hesitate  to 
emphasize  that  cocain  preparations  must  be  banished  from  injection 
anesthesia,  and  novocain  adopted  as  the  most  suitable  anesthetic 
up  to  date.  Port,  for  instance,  in  over  300  injections  of  a  i  per  cent, 
novocain  solution,  has  not  observed  one  single  case  of  intoxication, 
while  he  noted  several  unmistakable  instances  of  intoxication  in  an 
equal  number  of  control  injections  of  cocain,  one  of  which  was  serious. 

In  view  of  the  glaring  advertisements  of  various  anesthetics  which 
are  shrouded  in  more  or  less  mystery,  it  is  about  time  for  us  to  eman- 
cipate ourselves  from  the  manufacturer's  tutelage  and  to  go  our  own 
way,  which  has  been  clearly  indicated  by  unselfish  investigators.  In 
the  hands  of  an  operator  who  has  learned  to  master  the  technique  of 
injection,  novocain  solution  will  never  be  found  wanting.  Most  cases 
of  failure  are  undoubtedly  due  to  a  lack  of  technical  skill,  as  has  been 
freely  admitted  by  many  dentists  who  have  learned  or  practised  local 
anesthesia  in  our  clinic.  For  this  reason  an  elaborate  description  of 
the  technique  of  injection  is  offered  in  this  volume,  as  this  feature  is 
really  much  more  difficult  than  may  appear  at  first  glance. 

Novocain,  as  has  been  stated,  is  the  leading  substitute,  and  owing 
to  its  numerous  advantages  is  being  more  and  more  generally  intro- 
duced in  dentistry.  It  has  already  found  its  place  in  surgery,  and 
seems  to  be  destined  to  supplant  cocain  entirely.  Fortified  by  an 
extensive  experience  with  anesthesia  by  novocain  solution,  we  shall 
therefore  speak  chiefly  of  that  preparation,  and  refer  to  cocain  and 
its  application  by  way  of  comparison  only,  since,  as  Braun  says, 
"cocain  has  become  obsolete  in  surgery,  and  is  no  longer  used.  The 
drug  houses,  of  course,  will  continue  to  make  the  old  preparations  as 
long  as  there  is  any  demand  for  them." 


CHEMICAL  METHODS  OF  ANESTHESIA  43 

Quinin    and    Urea   Hydrochlorid    Compounds    Contra-indicated. — 

Certain  quinin  compounds,  Riethmliller^  writes,  have  within  recent 
years  been  employed  for  the  production  of  local  anesthesia  in  minor 
surgery,  and  the  combination  of  quinin  and  urea  hydrochlorid  has 
received  quite  some  discussion  among  the  dental  profession  to  whom 
this  combination  has  been  offered  under  proprietary  names.  A 
great  many  untoward  sequelae,  however,  have  been  produced  by  its 
use  hypodermically,  such  as  local  hemorrhage,  oozing,  extensive 
sloughing,  abscess,  continued  fever,  swelling,  gangrene,  and  tetanus.- 
Boiling  of  quinin  for  the  purpose  of  sterilization  not  only  produces 
deterioration  of  the  drug  chemically,  but  materially  impairs  its  thera- 
peutic efficiency.  H.  Prinz^  scrutinizes  the  value  of  this  anesthetic 
compound,  and  reaches  the  following  damaging  conclusions:  While 
it  is  true  that  quinin  and  urea  hydrochlorid  is  not  poisonous  in  the 
doses  in  which  it  is  injected  for  local  anesthesia  purposes,  yet,  since 
it  reacts  strongly  acid,  it  severely  damages  the  tissues  in  the  injected 
area,  edema  and  induration  being  the  usual  sequelae.  The  injection  is 
more  or  less  painful,  and  the  mixture  interferes  with  the  progress  of 
wound-healing.  The  excessive  length  of  duration  of  the  anesthesia, 
and  the  paralysis  persisting  from  several  hours  to  several  days,  is  most 
disagreeable  and  often  alarming  to  the  patient.  If  applied  in  concen- 
trated solution  to  the  mucous  surfaces,  this  compound  is  only  sparingly 
absorbed,  and  very  little  anesthesia  is  produced.  Besides,  its  most 
persistent  bitter  taste  renders  its  use  undesirable  for  this  purpose. 
"From  the  foregoing  we  conclude  that  quinin  and  urea  hydrochlorid, 
when  employed  as  a  local  anesthetic  in  dental  operations,  possesses 
no  advantages  as  compared  to  novocain.  While,  a  priori,  its  non- 
poisonous  nature  indicates  safety,  this  safety  is  only  relative,  as  it 
refers  to  larger  doses.  The  small  dose  of  novocain  necessary  for  the 
average  dental  operation  may  be  considered  a  safe  dose." 

'  Dental  Cosmos,  February,  1913. 

2  Ibid.,  February,  1911,  p.  253;  October,  1913,  p.  1061;  November,  1913,  p.  1196. 

*  Ibid.,  January,  191 1. 


44  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


NOVOCAIN    AND    ITS    SOLUTIONS. 

Secret  Preparations  of  Local  Anesthetics. — While  a  great  many  local 
anesthetics  with  fancy  names  and  of  secret  or  only  partly  disclosed 
composition  are  in  the  market,  it  is  significant  to  note  that  within  the 
last  year  a  few  of  the  most  popular  are  being  manufactured  with  novo- 
cain as  their  active  anesthetic  principle  instead  of  cocain  as  formerly. 
These  ready-made  secret  solutions  are  not  very  stable,  unless  they 
contain  strong  preservatives  which  are  highly  irritating  to  the  tissues. 
Moreover,  as  Riethmiiller  writes,  "the  large  majority  of  these  prepa- 
rations should  be  shunned  by  any  practitioner  who  respects  the  scien- 
tific standard  of  his  profession.  From  a  merely  practical  point  of 
view  it  should  be  remembered  that  the  price  of  these  proprietaries  is 
too  high  in  comparison  to  their  efficiency,  and  the  mystery  in  which 
the  manufacturers  shroud  the  composition  of  their  products  puts  the 
operator  at  a  great  disadvantage  medicolegally  in  case  of  suit  for 
damages  following  any  accident." 

For  the  selection  of  an  anesthetic,  the  following  principles  have 
been  laid  down  by  Braun: 

1.  The  local  anesthetic  must  be  less  toxic  than  cocain. 

2.  It  must  not  cause  any  tissue  lesions. 

3.  It  must  be  soluble  in  water,  and  its  solutions  must  be  sterilizable. 

4.  It  must  allow  of  combination  with  suprarenal  preparations. 
Novocain. — Novocain  fulfils  these  requirements.     It  was  discovered 

by  Einhorn  in  1905.  It  is  a  white  powder,  readily  soluble  in  water  in 
equal  proportions.  The  salt  crystallizes  in  alcohol  in  the  form  of  small 
needles  which  melt  at  156°  C.  It  dissolves  in  the  proportion  of  i  to  i 
in  water,  forming  a  neutrally  reacting  liquid.  In  cold  alcohol  it  is 
soluble  at  the  ratio  of  i  to  30.  The  solutions  can  be  heated  up  to 
120°  C.  without  undergoing  decomposition.  After  suprarenal  extract 
has  been  added  to  a  novocain  solution  the  mixture  should  be  boiled 
for  a  short  time  only,  as  the  active  principle  of  suprarenin  loses  its 
effect  by  continued  boiling,  and  the  drug  itself  is  decomposed. 

Novocain  has  the  same  action  on  the  peripheral  sensory  nerves  as 


NOVOCAIN  AND  ITS  SOLUTIONS  45 

cocaln.  A  1.5  per  cent,  solution  is  fully  sufficient  to  anesthetize  within 
ten  minutes  even  large  nerve  trunks. 

''The  I  per  cent,  novocain-suprarenin  solution  serves  almost  all 
purposes  and  is  most  suitable  for  general  practice.  .  .  .  Without 
fear  of  toxic  secondary  effects,  1.25  gram  novocain,  i.  e.,  250  c.c.  of  a  0.5 
per  cent,  solution,  or  125  c.c.  of  a  i  per  cent,  solution,  and  more,  can 
be  injected.  If  a  2  or  a  4  per  cent,  solution  is  employed,  a  dose  of  0.8 
gram  novocain,  i.  e.,  40  or  20  c.c.  of  these  solutions  respectively,  should 
not  be  exceeded;  for  injections  into  tense  and  highly  vascular  tissue, 
such  as  the  gingivae,  a  lower  dose  will  suffice.  On  the  whole,  little 
attention  need  be  given  to  the  dosage  of  novocain,  unless  an  attempt 
is  being  made  to  operate  under  local  anesthesia  in  an  all  but  hopeless 
case  that  presents  an  enormous  operative  field.  To  this  feature  of 
novocain  the  remarkable  progress  of  local  anesthesia  is  in  a  large 
measure  due."     (Braun.) 

Systemic  Effects  after  Absorption. — The  systemic  effects  after  the 
absorption  of  novocain  are  hardly  noticeable,  neither  circulation  nor 
respiration  being  influenced.  The  heart  action  is  not  affected.  From 
0.15  to  0.2  gram,  when  injected  subcutaneously  in  rabbits,  produces 
hardly  any  change  in  the  tracings  of  blood-pressure  and  respiration 
as  registered  by  the  kymograph.  Novocain  does  not  produce  mydriasis, 
disturbances  in  accommodation,  or  increase  in  intra-ocular  pressure. 
Its  low  toxicity  can  easily  be  demonstrated  by  comparing  the  lethal 
dose  of  novocain  with  that  of  cocain  or  stovain  per  each  kilogram  of 
body  weight  in  different  animals. 

The  comparative  lethal  doses  of  these  drugs,  when  injected  sub- 
cutaneously, are  per  kilogram  body  weight:  In  rabbits,  novocain, 
from  0.35  to  0.4  gram;  cocain,  from  0.05  to  o.i  gram;  in  dogs,  novo- 
cain, 0.25  gram  (not  yet  lethal) ;  cocain,  from  0.05  to  0.07  gram. 
The  minimal  lethal  dose  in  rabbits  per  kilogram  body  weight  is  0.73 
gram  of  novocain  when  injected  subcutaneously  in  a  10  per  cent, 
solution. 

Effects  of  Novocain. — Novocain  solutions  are  absolutely  non- 
irritant.  Even  if  20  per  cent,  solutions  or  the  pure  powder  are  intro- 
duced into  fresh  wounds,  not  only  no  untoward  symptoms  whatever 


46  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

are  observed,  but  the  local  inflammation  is  reduced,  as  we  have  been 
able  to  demonstrate.  Solutions  can  be  boiled  any  number  of  times 
without  disintegration.  The  toxic  effect  of  novocain  is  relatively 
light.  In  very  high  doses  tonicoclonic  spasms,  together  with  opisthot- 
onos, great  agitation,  accelerated  and  shallow  respiration,  are  noted. 
The  maximal  dose  for  subcutaneous  injection  is  0.8  gram.  Novocain 
is  seven  times  less  toxic  than  cocain,  and  three  times  less  toxic  than 
its  other  substitutes. 

Novocain  has  a  transitory  vasodilator  effect,  but  is  fully  equal  to 
cocain  in  its  anesthetic  power.  The  unfavorable  vasodilator  action  of 
novocain  is  counteracted  by  combination  with  suprarenal  extract; 
in  fact,  its  anesthetizing  power  is  considerably  enhanced  by  this 
admixture. 

Another  great  advantage  of  novocain,  which  Riethmiiller  wishes 
to  emphasize,  lies  in  the  fact  that  it  is  not  a  habit-forming  drug.  This 
is  of  vital  importance  when  we  remember  that  many  an  unfortunate 
victim  of  the  cocain  habit  has  been  started  in  this  fatal  practice  by  the 
application  of  cocain  by  well-meaning  dentists  or  rhinologists.  Since 
the  legislatures  of  several  states  of  the  Union  have  placed  the  ban 
upon  the  sale  of  cocain  and  cocain  mixtures  except  upon  a  physician's 
prescription,  the  exemption  of  novocain  from  such  laws  is  a  matter  of 
momentous  interest  to  the  dentist. 

Consequently,  as  Braun  has  declared,  novocain  is  "an  ideal 
anesthetic  which  can  not  only  be  substituted  for  cocain  in  every 
case,  but  considerably  enhances  the  safety  of  local  anesthesia  owing 
to  the  possibility  of  safely  injecting  much  greater  quantities  of  a 
strongly  active  anesthetizing  solution." 

Opinions  Regarding  Novocain. — "We  must  emphasize  that  our 
experiences  fully  coincide  with  those  of  Braun,  Hainecke  and  Laewen. 
The  results  of  255  observations  have  proved  that  novocain  is  a  non- 
irritant,  rapid  and  intensely  effective  local  anesthetic,  which  pro- 
duces no  toxic  secondary  effects,  no  irritation  or  necrotic  symptoms. 
Novocain  does  not  impair  the  action  of  suprarenin  in  the  least,  and 
can  be  well  sterilized.  We  have  arrived  at  the  conviction  that  novo- 
cain at  present  is  the  only  known  agent  fit  to  take  the  place  of  cocain 


NOVOCAIN  AND  ITS  SOLUTIONS  47 

in  surgery,  and  we  can  warmly  recommend  it  for  use  in  medical  prac- 
tice."    (Danielsen.) 

"A  resume  of  our  clinical  experiences  shows  that  novocain  repre- 
sents a  non-toxic  and  superior  substitute  for  cocain  for  the  purpose 
of  local  anesthesia  by  injection  in  the  tissues,  its  maximal  dose  is  0.5 
gram,  it  allows  of  an  ideal  combination  with  suprarenin,  and  produces 
absolutely  no  irritation."      (Liebl.) 

Novocain-suprarenin. — "The  effect  of  suprarenin,  far  from  being 
impaired  by  novocain,  seems  to  be  enhanced  by  this  drug,  as  my  very 
first  tests  have  shown  and  numerous  subsequent  investigations  have 
corroborated.  The  anemia  which  follows  novocain-suprarenin  injec- 
tion is  much  more  pronounced  than  when  a  pure  suprarenin  solution 
or  a  cocain  solution  containing  an  equal  amount  of  suprarenin 
is  employed.  Independently  of  my  observations,  Dr.  Biberfeld  had 
noted  the  same  curious  fact.  The  combination  of  novocain  and  supra- 
renin, and  the  behavior  of  these  two  drugs  toward  one  another,  is  of 
great  advantage  in  local  anesthesia,  inasmuch  as  only  very  small 
quantities  of  suprarenin  are  needed  to  intensify  the  local  anesthetic 
action  of  novocain  to  as  high  a  degree  as  is  peculiar  to  cocain- 
suprarenin  solutions.  These  small  admixtures  of  suprarenin  also 
retard  absorption  and  thereby  render  the  anesthetic  action  purely 
local  and  limited  to  the  place  of  injection.  The  power  of  these 
novocain  solutions  in  regard  to  intensity,  duration,  and  extension  of 
anesthesia  is  at  least  as  great  as  that  of  cocain  solutions.  All  the 
operations  described  in  my  book  can  equally  well  be  performed  with 
novocain  as  with  cocain  solutions.  For  infiltration  and  conductive 
anesthesia,  novocain  in  combination  with  suprarenin  is  the  most 
suitable  agent."      (Braun.) 

Suprarenin. — ^Suprarenin  is  derived  from  the  suprarenal  gland  and 
possesses  the  specific  property  of  contracting  the  walls  of  the  capillaries 
and  small  bloodvessels  within  an  injected  area.  The  toxic  effect  of 
the  injected  anesthetic  solution  is  thus  minimized  and  its  absorption 
retarded  while,  at  the  same  time,  anemia  is  produced  so  that  the 
field  of  operation  remains  unobstructed  by  parenchymatous  hemor- 
rhage.     In   former  years,   suprarenal   preparations  were  secured   from 


48  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

the  suprarenal  glands  of  sheep  and  oxen.  Synthetically  prepared 
suprarenin,  however,  is  much  purer,  less  toxic,  and  more  stable  than 
the  organic  product. 

Suprarenin  is  a  grayish-white  powder,  slightly  soluble  in  water, 
and  readily  soluble  in  dilute  acids.  It  is  the  most  powerful  of  all 
chemical  substances  thus  far  known,  being  active  even  in  a  dilution 
of  I  in  100,000.  Its  toxicity  is  therefore  relatively  high,  and  more 
than  0.5  mg.  should  never  be  injected  in  one  dose.  The  toxic  symptoms 
produced  by  suprarenin  consist  chiefly  in  palpitation  of  the  heart, 
oppression,  and  difficult  respiration. 

Suprarenin  has  no  anesthetizing  power,  but,  as  has  been  said, 
produces  contraction  of  the  small  bloodvessels  and  capillaries.  A  solu- 
tion of  I  to  1000  seems  to  be  most  favorably  indicated  for  injection. 

Contraction  of  the  bloodvessels  occurs  also  when  suprarenal  extract 
is  applied  locally  to  the  mucous  membranes,  or  injected  into  the  tissues. 

Suprarenin,  according  to  the  findings  of  Kochmann  and  Esch^ 
has  the  property  of  preparing  the  nerve  tissue  for  the  reception  of 
the  local  anesthetic,  in  about  the  same  manner  as  a  mordant  is  applied 
in  the  dying  industry  for  rendering  the  cloth  more  receptive  of  the 
dyestuff. 

Adrenalin,  a  suprarenal  preparation  of  English  manufacture,  is 
mixed  with  a  small  quantity  of  chloretone  for  the  purpose  of  rendering 
the  solution  more  stable.  This  effect  of  chloretone,  however,  has 
been  disputed  by  B.  Mtiller,  who  found  that  chloretone  impairs  the 
action  of  adrenalin. 

Stability  of  Suprarenin  Solution. — Even  synthetic  suprarenin  is 
stable  only  to  a  limited  degree  after  the  bottle  has  once  been  opened; 
for  this  reason  the  transferring  into  another  vessel  of  the  quantity 
required  in  every  case,  as  recommended  by  Seidel,  seems  impracticable. 
In  private  practice  it  is  best  to  make  a  fresh  solution  from  tablets, 
as  cases  present  themselves.  "The  very  convenient  tablets,"  as 
Braun  writes,  "are  preferable  to  any  other  form  of  dispensing  alkaloids 
used  for  medical  purposes.  This  is  especially  true  of  unstable  drugs 
like  suprarenin  which,  in  dry  tablet  form,  keeps  for  a  long  time." 

1  Deutsch.  Zahnarztliche  Wochenschrift,  vol.  ii,  p.  65. 


NOVOCAIN  AND  ITS  SOLUTIONS  49 

For  injection,  a  slightly  acidulated  sodium  chlorid  solution  is 
used  as  a  base  to  which  suprarenin  is  added  in  the  concentration  of 
I  in  I  GOO.  Even  fractions  of  i  mg.  of  suprarenin  suffice  to  produce 
anemia  in  a  very  large  operative  field,  if  the  anesthetic  mixture  has 
been  introduced  in  sufficient  quantity  and  evenly  distributed  in  the 
tissue,  i.  e.,  along  the  periphery  of  the  area  to  be  operated  upon. 

If  synthetic  suprarenin  is  exposed  to  light  for  some  time,  the 
originally  clear  solution  undergoes  a  reddish,  later  a  yellowish,  dis- 
coloration. Any  slightly  discolored  solution  is  unsuitable  for  use, 
as  the  toxicity  of  the  drug  is  considerably  increased  by  the  chemical 
changes  which  produce  the  discoloration. 

Biberfeld  has  ascertained  that  synthetic  suprarenin  is  also  clinically 
equal  to  the  organic  product.  In  my  opinion,  however,  the  organic 
product  generally  exhibits  greater  toxicity  than  the  synthetic  prepa- 
ration. 

Action  of  Suprarenin. — Suprarenin  is  dispensed  and  used  in  physio- 
logical salt  solution.  If  applied  externally  upon  the  mucous  tissue, 
the  solution  produces  anemia  within  from  one-half  to  five  minutes; 
if  injected  hypodermically,  in  from  fifteen  to  thirty  seconds.  The 
anemia  is  complete  as  soon  as  the  originally  pink  mucous  tissue  has 
assumed  a  pale,  whitish  shade.  The  action  of  the  solution  extends 
only  within  a  radius  of  from  i  to  2  cm.  After  the  anemia  has  disap- 
peared, primary  dilatation  of  the  bloodvessels  ensues,  until  gradually 
the  vascular  walls  return  to  their  normal  condition. 

Toxicity  of  Suprarenin. — Suprarenin  may  exhibit  an  intensely 
toxic  action  if  introduced  into  the  circulation  in  excessive  quantity 
or  concentration.  The  toxicity  is  greatest  when  the  drug  is  injected 
intravenously,  viz.,  directly  into  the  blood.  According  to  Batelli,  its 
toxicity  is  forty  times  greater  when  it  is  injected  intravenously  than 
when  it  is  introduced  subcutaneously.  Even  the  doses  employed  for 
dental  purposes  sometimes  produce  untoward  toxic  symptoms,  such 
as  palpitation  of  the  heart,  acceleration  of  pulse,  dizziness,  fainting, 
and  collapse,  especially  if  stale  solutions  are  employed.  This  danger 
is  reduced  to  a  minimum  if  a  fresh  solution  is  prepared  from  tablets, 
while  solutions  made  with  liquid  suprarenin  are  always  risky. 
4 


50  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

The  maximal  dose  of  suprarenin  may  be  said  to  be  lo  drops  of  a 
I  to  1000  solution  of  the  synthetic  preparation. 

The  size  of  the  drops  is  measured  by  a  standard  pipette.  Seidel 
justly  emphasizes  accuracy  in  the  size  of  the  drops,  after  having  shown 
that  3  c.c.  of  synthetic  suprarenin  furnished  36  drops  with  a  dropper, 
93  with  a  pipette,  and  45  with  the  original  bottle.  Organic  supra- 
renin differed  in  this  respect  from  the  synthetic  product,  the  same 
quantity  yielding  34,  73,  and  25  drops  respectively.  It  is  important 
to  avoid  the  sudden  introduction  of  a  large  quantity  of  the  drug  into 
the  blood.  Even  a  i  to  1000  solution  is  extremely  efficacious;  hence, 
when  injected  as  admixture  to  an  anesthetizing  solution,  suprarenin 
should  be  used  in  more  dilute  form. 

The  Standard  Pipette. — Dr.  Schonbeck  has  endeavored  to  design 
a  so-called  standard  pipette  which  would  be  most  suitable  for  practice. 
He  made  the  interesting  observation  that  all  the  standard  pipettes, 
as  bought  from  various  apothecaries,  furnished  drops  of  different  sizes, 
proving  that  there  was  no  uniform  standard  pipette.  We  have  figured 
that  I  c.c.  of  I  to  1000  synthetic  suprarenin  should  be  divided  into  32 
drops  in  order  to  insure  the  normal  dose  of  suprarenal  extract.  This 
requirement  is  fulfilled  by  Dr.  Schonbeck's  so-called  "Tested  Standard 
Pipette." 

Seidel  has  recently  suggested  a  small  instrumentarium  for  the 
preparation  of  fresh  novocain-suprarenin  solutions,  in  which  a  pipette 
of  dark  glass  and  with  double  cover  is  included.  This  pipette,  when 
being  held  vertically,  yields  31  drops  per  i  gram  of  i  in  1000  supra- 
renin. Two  drops  of  suprarenin  added  to  3  c.c.  of  a  novocain  solution 
give  the  average  dosage  of  0.00002  per  i  c.c,  as  indicated  by  Seidel.^ 
With  every  dropper  it  must  be  ascertained  "how  many  drops  per  i  c.c. 
it  produces.  Unless  this  precaution  is  taken,  dosage  by  drops  is 
absolutely  unreliable."     (Braun.) 

No  Tissue  Lesions  from  Suprarenin. — A  fortunately  rare  danger 
consists  in  postoperative  hemorrhage,  which  has  been  observed  in 
reaction  to  the  abnormal  vascular  contraction  followed  by  hyperemia, 
especially  after  tooth  extractions.     Suprarenin  by  its  extremely  local 

1  Deutsch.  Monats.  f.  Zahnheilkunde,  191 1,  p.  889. 


NOVOCAIN  AND  ITS  SOLUTIONS  51 

action  most  effectively  retards  the  process  of  local  circulation,  and, 
in  some  cases,  may  endanger  the  dental  pulp.  This  danger,  however, 
does  not  seem  to  exist  with  the  now  generally  adopted  dosage  of  our 
injecting  solutions,  as  Euler  and  Scheff  have  recently  proved  by 
experiment.  The  latter  found  that  novocain-suprarenin  solutions 
do  not  in  the  least  disturb  either  the  vitality  of  the  teeth  anesthetized 
or  that  of  the  approximating  teeth,  "provided  the  perfect  vitality  of 
the  pulp  before  application  of  the  drug  has  been  established  beyond 
all  doubt."     (Scheff.) 

Suprarenal  extracts,  especially  suprarenin-Hoechst,  are  marketed 
in  the  form  of  i  in  looo  solutions  ready  for  use,  to  which  a  slight  trace 
of  hydrochloric  acid  has  been  added  for  the  sake  of  stability,  or  in 
the  shape  of  compressed  tablets  of  i  mg.  each.  One  of  these  tablets 
is  calculated  to  be  added  to  about  50  c.c.  of  a  2  per  cent,  novocain 
solution.  The  combination  tablets  E  and  G,  however,  which  contain 
novocain  together  with  the  proper  small  percentage  of  suprarenin, 
are  far  more  practical.  While  in  ready  solution  suprarenin  keeps 
for  a  short  time  only,  it  remains  unchanged  for  a  long  period  in  the 
dry  tablet  form.  Since  the  sterility  of  these  tablets  is  not  always 
uniform  and  certain,  solutions  made  from  tablets  must  be  sterilized 
before  use.  Braun  recommends  the  addition  of  a  trace  of  hydrochloric 
acid  to  the  normal  saline  solution  in  which  the  tablets  are  dissolved, 
i.  e.,  3  drops  of  dilute  hydrochloric  acid  to  one  liter  of  normal  saline 
solution. 

In  his  opinion,  the  dosage  of  suprarenin  is  of  little  importance  in 
local  anesthesia,  because  the  dilutions  of  i  in  100,000  and  of  i  in 
200,000  will  not  produce  any  systemic  effects.  Hospital  internes  are 
employing  considerable  doses  in  collapse  due  to  infectious  diseases, 
i.  e.,  as  much  as  6  mg.  per  day,  even  24  mg.  per  day.  (Kirchheim.) 
The  doses  required  in  local  anesthesia  may  therefore  be  considered 
innocuous  as  long  as  a  pure  and  fresh  preparation,  preferably  one 
made  from  tablets,  is  employed. 

The  concentration  of  the  suprarenin  in  the  anesthetic  solution, 
however,  is  of  importance,  as  it  determines  the  intensity  of  the  local 
effect  of  the  anesthetic  and   the  duration  of  anemia.     This  anemia 


52  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

should  never  be  so  pronounced  as  to  interrupt  the  circulation  of  the 
blood  completely.  Excessively  strong  suprarenin  may  cause  gan- 
grene, especially  in  arteriosclerotics.  Generally,  however,  the  doses 
indicated  above  produce  no  untoward  action  whatever  in  the  tissues. 
In  patients  with  heart  disease,  in  children,  and  in  the  aged,  it  is 
advisable  to  reduce  the  concentration  of  the  suprarenin  by  adding  to 
one  tablet  E  a  little  more  of  the  Ringer  solution  (see  page  163),  i  c.c. 
of  which  gives  a  2  per  cent,  novocain-suprarenin  solution  when  one 
tablet  E  is  dissolved  in  it.  The  excess  of  Ringer  solution  also  reduces 
the  novocain  contents,  and  a  less  toxic  solution  is  obtained,  but  the 
anesthetizing  power  of  the  solution  is  still  more  than  sufficient,  as 
innumerable  practical  cases  have  shown.  The  tablet  G,  which  yields 
a  1.5  per  cent,  novocain-suprarenin  solution  is  even  less  toxic,  though 
quite  efficacious  when  dissolved  in  a  greater  quantity  of  Ringer  solution. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN. 

The  Injecting  Solution. — Novocain-suprarenin  solutions  which  are 
intended  for  injection  must  always  be  of  the  purest  quality;  they  must 
be  crystal-clear  and  not  contain  any  admixtures;  nor  must  they  have 
come  in  contact  with  any  impurities  during  the  process  of  prepara- 
tion. Toxic  secondary  effects  may  occur  if  the  solution  has  not  been 
sufficiently  protected  from  light  and  heat  and  subsequent  decompo- 
sition, which  is  evidenced  by  the  flocculent  appearance  of  the  solution. 

The  quality  of  an  injecting  solution  is  also  generally  evinced  by  its 
behavior  toward  the  living  organism.  It  should  penetrate  the  tissue 
cells  without  producing  any  lesions  in  the  way  of  distention  or  con- 
traction.    This  property  of  a  solution  is  called  isotonia. 

Isotonia. — Every  body  cell  is  protected  from  the  tissue  fluids  by  a 
semipermeable  membrane  which  regulates  the  interchange  of  the 
fluids  between  the  cell  contents  and  the  cell  environment,  i.  e.,  main- 
tains metabolism.  If  the  fluids  within  and  without  the  cell  are  of  the 
same  consistency,  if  their  percentage  in  salts  is  the  same,  then  isotonia 
or  equal  tension  is  present.     If,  however,  the  percentage  in  salts  in 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  53 

the  environment  of  the  cell  exceeds  that  within  the  cell,  then  there  is 
a  tendency  to  equalization.  Since,  however,  only  water,  not  salts, 
diffuses  through  the  plasmatic  membrane,  the  salts,  on  the  other  hand, 
have  a  tendency  to  absorb  the  water  from  the  cells,  the  water  leaves 
the  cells,  causing  a  contraction;  or,  if  the  reverse  is  the  case,  i.  e.,  the 
cell  environment  is  deficient  in  salts,  a  distention  of  the  cell  ensues. 
The  power  that  regulates  this  interchange  is  called  osmotic  pressure. 
Cell  disturbances  are  caused  by  difference  in  concentration,  i.  e., 
difference  of  osmotic  pressure  on  either  side  of  the  cell  membrane. 
If,  then,  a  solution  is  injected  which  does  not  conform  with  the  amount 
of  salts  in  the  tissue,  the  cells  are  either  contracted  or  distended.  The 
absorption  of  the  injected  solution  is  retarded  and  a  pathological 
condition  ensues  which  often  assumes  the  form  of  edema.  Hypertonic 
solutions,  i.  e.,  those  rich  in  salts,  and  hypotonic  solutions,  i.  e.,  those 
poor  in  salts,  may,  in  unfavorable  cases,  produce  necrosis  of  the  tissues, 
especially  when  they  contain  highly  toxic  drugs  such  as  cocain. 

Non-isotonic  Preparations. — Numerous  solutions  in  the  market 
not  only  contain  admixtures  of  highly  toxic  drugs  but  also  lack  sufft- 
cient  neutrality;  in  other  words,  they  are  not  isotonic  but  heterotonic, 
if  we  may  use  this  term,  as  has  been  proved  by  the  writer's  former 
assistants,  Buente  and  Moral.  Hemolysis  of  the  human  blood  cor- 
puscles was  produced  by  the  following  drugs:  Bernatzik's  solution, 
Wilson's  anesthetic,  Krause's  world  anesthetic,  adralgin,  Winter's 
anesthetique  local,  Bonnighausen's  local  anesthetic  "corona,"  sub- 
cain  (which  induced  the  formation  of  methemoglobin),  nalicin,  andolin, 
udrenin,  Pohl's  a-c  subcutaneous  tablets,  phenyphrin  (which  also 
induced  the  formation  of  methemoglobin),  orthonal,  Ritsert's  simplex 
subcutin,  Witte's  local  anesthetic,  dolorant  (producing  incipient 
hemolysis),  Schroder's  analgesic,  and  dolantin. 

In  contrast  tO  these,  novocain  penetrates  the  tissue  cells,  the  red- 
blood  corpuscles,  etc.,  without  producing  any  irritation;  it  in  nowise 
impairs  the  hemoglobin,  and  permeates  even  the  nerve  substance, 
so  that  its  anesthetic  efTect  is  fully  developed. 

The  injected  fluid  rapidly  enters  the  circulation.  As  one  circula- 
tion  is  completed   in   the  human   body  within   twenty-seven  seconds, 


54  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

the  injected  fluid  reaches  the  heart  and  the  central  nervous  system 
within  about  thirteen  seconds.  This  explains  the  extraordinarily  rapid 
action  of  toxic  agents  when  injected  into  the  organism. 

Harmless  solutions,  such  as  the  novocain-suprarenin  solution 
advocated,  are  very  readily  excreted  by  the  urine  and  the  perspiration, 
so  that  untoward  effects  of  a  local  (edema)  or  general  nature  need 
not  be  anticipated. 

Besides  the  above-mentioned  conditions,  an  injecting  solution 
must  fulfil  the  following  requirements: 

1.  The  solution  should  not  be  detrimental  to  the  blood  or  the 
tissue  cells. 

2.  It  should  not  alter  the  hemoglobin. 

3.  It  should  not  produce  any  distention  or  contraction  of  the  cells 
or  hemolysis;  it  must  be  isotonic.     Its  freezing-point  must  be  about 

-0.55°  c. 

4.  It  should  contain  an  accurately  determined  average  amount  of 
the  anesthetic. 

5.  It  should  not  react  acid. 

6.  It  should  be  free  from  unnecessary  or  harmful  admixtures. 

Addition  of  Thymol. — The  addition  of  an  antiseptic  for  the  pur- 
pose of  greater  stability  of  the  solution  has  been  abandoned  on  the 
strength  of  the  clinical  experiences  of  the  last  two  years.  The  admix- 
ture of  thymol  as  formerly  recommended  may  produce  a  more  or  less 
painful  irritation  during  the  injection  of  the  solution.  In  my  opinion, 
and  according  to  recent  observations,  this  pain  is  not  uniform,  and 
even  if  it  is  present  its  intensity  is  minimal.  A  great  many  practitioners 
still  adhere  to  the  addition  of  thymol,  as  it  does  not  produce  any 
tissue  lesions.  Fresh  solutions  made  from  tablets,  however,  do  not 
require  any  admixture  for  the  purpose  of  greater  stability,  so  that 
thymol  can  be  omitted  without  any  detriment  to  the  solution. 

Temperature  of  the  Solution. — The  temperature  of  the  solution 
should  correspond  as  nearly  as  possible  to  that  of  the  tissues.  The 
farther  we  deviate  from  this  optimum  temperature,  especially  on  a 
downward  scale,  the  greater  is  the  likelihood  of  irritations  resulting. 
Injections  of  very    cold    or  hot   (above  +55°   C.)   solutions  produce 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  55 

serious  tissue  lesions,  usually  followed  by  extremely  painful  infiltra- 
tions. The  latter  occur  also  when  the  solution  is  not  quite  sterile,  or 
when  the  admixtures,  especially  the  suprarenin,  have  undergone 
alteration  or  decomposition. 

Recent  investigations  of  Moral  have  shown  that  temperature 
has  a  pronounced  influence  upon  the  anesthetic  power  of  the  solu- 
tion, which  should  be  injected  at  body  heat.  Solutions  of  that  tem- 
perature have  proved  to  be  most  satisfactory.  This  condition  can 
be  easily  brought  about  in  making  a  solution  from  tablets.  After 
boiling,  the  solution  is  quickly  drawn  into  the  syringe  and  injected, 
as  it  then  has  the  optimum  temperature. 

Ampoules. — For  the  requirements  of  daily  practice  it  seemed 
expedient  to  dispense  novocain-suprarenin  in  ampoules  so  as  to  offer 
the  solution  ready  for  use  in  convenient  form.  Our  experiences  with 
these  ampoules,  however,  induce  us  to  give  the  preference  to  solu- 
tions freshly  made  from  tablets,  for  the  present  at  least.  The  ampoule 
solution  decomposes  more  quickly,  and  its  stability  depends  upon  the 
conditions  of  temperature  and  light  under  which  it  is  preserved. 
Although  it  is  possible  to  market  stable  ampoule  solutions  if  all  pre- 
cautionary measures  are  strictly  observed,  the  manufacture  of  these 
solutions  is  variable  and  uncertain.  Besides,  suprarenal  extract  is  not 
stable  for  any  length  of  time  when  in  liquid  union  with  novocain. 

In  medicine,  nevertheless,  thousands  of  ampoules  are  being  used 
daily.  We  are  continually  conducting  experiments  with  ampoules, 
and  do  not  hesitate  to  confess  that,  as  soon  as  it  becomes  possible  to 
eliminate  all  imperfections,  the  ampoule  solution  will  be  the  ideal 
of  convenience  for  innumerable  practitioners.  We  have  employed 
preparations  which  were  twelve  weeks  old  and  over,  and  upon  opening 
found  the  solution  crystal-clear  and  no  less  perfect  in  regard  to  anes- 
thetic power  than  a  freshly  prepared  solution.  The  process  of  manu- 
facturing ampoules,  however,  is  not  as  yet  generally  perfected  so  as 
to  guarantee  their  durability  absolutely;  especially  the  technique  of 
sealing  the  sterile  contents  of  the  ampoule  by  fusing  the  neck  seems 
difficult  and  uncertain,  and  even  first-class  laboratories  .sometimes 
market  ampoules  which  arc  unsuitable  for  use  after  a  very  short  time, 


56  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

because  they  are  not  hermetically  sealed.  It  is  probable,  however, 
that  the  experiments  toward  improving  the  technical  procedures  of 
sealing  ampoules  and  testing  each  one  in  a  vacuum  will  shortly  lead 
to  satisfactory  and  fully  reliable  results.  The  small  glass  splinters 
which  may  be  produced  in  breaking  the  neck  of  an  ampoule,  do  not 
seem  to  constitute  a  weighty  contra-indication,  and  no  untoward 
consequences  from  this  source  have  ever  been  reported.  In  short,  an 
improvement  in  the  manufacture  of  ampoules  will  soon  prove  their 
eminently  practical  value. 

The  closing  of  ampoules  with  small  rubber  disks  is  to  be  discoun- 
tenanced, because  the  sulfur  compounds  in  rubber  imperil  the  stability 
of  a  solution  containing  suprarenin  admixture.  This  has  been  shown 
by  the  decomposition  of  suprarenin  in  bottles  closed  with  rubber 
stoppers;  since  these  have  been  substituted  with  glass  stoppers,  supra- 
renin solutions  are  more  uniform  and  stable. 

Those  practitioners  who  employ  ampoule  preparations  of  reliable 
manufacture  should  proceed  as  follows: 

Ampoules  must  be  kept  as  aseptic  as  every  other  instrument  used 
for  injection.  The  unbroken  ampoule  contains  a  sterile  solution,  yet  its 
outer  surface  is  by  no  means  sterile.  It  passes  through  many  hands, 
is  packed  in  ordinary  cotton,  and  should  therefore  not  be  used  without 
having  been  previously  sterilized.  The  operator  is  cautioned  not  to 
nick  the  neck  of  the  ampoule  with  a  file  in  order  to  break  it 
more  easily.  This  measure  invites  sepsis,  and  is  absolutely  unneces- 
sary, even  dangerous.  From  the  file  numerous  infectious  bacteria 
are  introduced  into  the  sterile  solution  after  the  neck  is  broken.  Am- 
poules are  best  sterilized  by  carefully  washing  some  half  dozen  in 
a  weak  solution  of  carbolic  acid  or  lysoform,  drying  and  preserving 
them  in  a  covered  glass  jar  or  tray  of  dark  violet  color  containing 
70  per  cent,  alcohol.  When  needed,  an  ampoule  is  taken  from  the 
alcohol  with  sterile  pincers  and  laid  between  sterile  gauze  or  cotton, 
the  neck  is  broken  in  the  gauze  while  inverting  the  ampoule — an 
easy  procedure — the  mouth  is  carefully  exposed,  and  the  contents 
are  drawn  out  through  an  iridio-platinum  hypodermic  needle  which 
has  previously  been  sterilized  by  passing  through  an  alcohol  flame. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  57 

Dr.  Schonbeck  has  made  interesting  experiments  in  order  to  ascertain 
whether  in  the  customary  process  of  opening  an  ampoule  with  the 
beaks  of  nippers  or  by  holding  it  in  a  clean  napkin,  the  sterile  solution 
can  be  infected,  and  to  what  degree.  In  these  tests  the  outer  surface 
of  the  ampoule  which  contained  a  sterile  solution  was  not  previously 
sterilized.  In  all  cases  the  solution  was  found  to  have  been  infected  in 
the  opening  process.  It  remained  sterile  only  when  carefully  manipu- 
lated in  the  manner  described. 

Tablets. — Since  the  preparation  of  novocain  solution  from  the 
powder,  with  suprarenin  added  in  drops,  is  not  sufficiently  reliable  and 
uniformly  practicable  in  daily  practice,  the  use  of  tablets  as  in  general 
vogue  in  surgery  is  given  the  preference. 

Sterility  of  Tablets. — Braun  bacteriologically  analyzes  every  year  the 
novocain  tablets  of  a  certain  drug  firm,  and  finds  them  always  sterile. 
Some  time  ago  Hoffmann  reported  that,  on  analyzing  tablets  from 
another  drug  firm,  he  discovered  that  over  one-half  contained  bac- 
teria. Professor  Riesel,  upon  Braun's  instigation,  analyzed  numerous 
tablets  of  the  first  make,  all  of  which  were  found  sterile.  Nevertheless 
there  is  a  possibility  of  tablets  occasionally  containing  bacteria. 

Upon  investigation  it  appears  that  novocain  tablets  will  keep  for 
years  if  protected  from  light  and  humidity.  Failures  are  due  to  other 
causes,  such  as  lack  of  cleanliness,  use  of  sodium  chlorid  solution 
contaminated  with  bacteria,  or  rinsing  of  the  syringe  with  lysol  or 
soda,  which  causes  decomposition  of  the  suprarenin.  The  physiologic 
salt  solution  employed  in  dissolving  these  tablets  must  be  absolutely 
free  from  soda  as  this  precipitates  alkaloids  and  decomposes  suprarenal 
preparations.     In  reference  to  this  phenomenon  Peuckert  says: 

"It  was  a  matter  of  great  importance  to  find  an  effective  and 
reliable  method  of  sterilization  for  these  tablets,  and  Braun,  after 
continued  experiments,  soon  arrived  at  a  practical  result.  He  recog- 
nized that  the  source  of  decomposition  of  suprarenin  solution  invari- 
ably lies  in  traces  of  alkalies  present  in  the  dissolving  media,  due 
partly  to  the  alkalinity  of  glass,  partly  to  other  causes.  If  suprarenin 
solution  is  boiled  in  absolutely  non-alkaline  sodium  chlorid  solution 
or    in    non-alkaline    distilled    water,    or    sterilized    by    steam,    in    a 


58  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

non-alkaline  glass  vessel  which  has  been  previously  treated  with  hydro- 
chloric acid,  the  solution  retains  its  color  and  full  power.  These  pre- 
cautions not  being  feasible  in  an  average  dental  office,  the  absolutely 
accurate  work  of  a  chemical  laboratory  is  required.  In  our  operating 
rooms,  where  lots  of  soap  and  soda  are  used,  it  is  impossible  entirely  to 
prevent  alkaline  traces  from  getting  into  the  solutions;  this  difficulty, 
however,  can  easily  be  overcome  by  other  means. 

"  To  one  liter  of  the  physiologic  salt  solution  to  be  used  in  dissolv- 
ing the  tablets,  2  drops  of  official  dilute  hydrochloric  acid  are  added. 
Solutions  made  from  novocain-suprarenin  tablets  in  this  slightly 
acidulated  salt  solution  may  then  be  either  boiled  or  sterilized  in 
steam  without  losing  any  of  their  power.  The  greater  stability  of 
this  solution  is  evident,  as  no  red  discoloration  at  all  occurs,  or,  if  any, 
only  after  prolonged  standing. 

"  No  physiologic  effects  from  this  added  tinge  of  dilute  hydro- 
chloric acid  can  be  noted  after  injection,  especially  no  tissue  lesions. 
On  the  other  hand,  the  hydrochloric  acid  suffices  to  neutralize  the 
alkaline  traces  which  may  be  present  in  the  salt  solution  or  in  the 
glass  vessels  employed,  and  which  invariably  remain  in  syringes  and 
needles  boiled  in  soda  solution,  even  if  these  are  rinsed  in  water  or 
sodium  chlorid  before  use." 

For  operations  in  the  mouth  Braun  dissolves  in  25  c.c.  of  salt  solu- 
tion one  tablet  containing  0.00016  borated  suprarenin  in  a  dilution 
of  I  to  150,000.  Of  this  0.5  per  cent,  novocain  solution  he  has  safely 
injected  up  to  150  c.c,  containing  0.00096  gram  suprarenin,  viz.,  more 
than  the  maximal  dose,  which  is  given  as  0.5  mg. 

During  the  1912  meeting  of  local  anesthesia  experts,  held  at 
Miinster,  it  was  the  consensus  of  opinion  that  a  freshly  made  solution 
of  novocain  mixed  with  suprarenal  extract  immediately  before  use 
was  most  desirable,  and  Seidel  showed  a  procedure  which,  according 
to  his  claims,  guaranteed  the  purity  of  the  solution.  But  even  Seidel's 
method  offers  no  absolute  certainty  that  the  two  component  parts  of 
the  solution,  especially  the  suprarenin,  will  keep  fresh  and  undecom- 
posed  for  more  than  a  few  days.  Even  such  a  simple  solution  as 
physiologic  sodium  chlorid,  though  preserved  in  specially  constructed 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  59 

stock  vessels  (see  Fig.  i),  will  not  remain  sterile  for  more  than  two  or 
three  weeks.  How  much  less  can  we  then  reasonably  expect  of  the 
stability  of  such  a  delicate  substance  as  suprarenin?  The  best  chemical 
works  invariably  warn  in  their  suprarenin  circulars  in  emphatic  terms 
that  the  stability  of  sterile  suprarenin  solutions  is  best  guaranteed 
by  preserving  them  in  the  original  bottles,  saying:  "Pouring  into 
dropping-bottles,  etc.,  is  contra-indicated." 

Braun  also,  who  undoubtedly  has  had  widest  experience  in  the 
question  of  solutions,  says:  "The  tablet  method  is  the  simplest  and 
most  reliable.  Outside  of  large  surgical  institutions  it  is  the  only 
one  which  should  be  recommended.  Practitioners  should  never  have 
solutions  of  alkaloids  made  by  an  apothecary  and  keep  them  in  a 
medicine  chest  until  needed.  An  incalculable  lot  of  damage  has  been 
done  by  such  practice."  The  argument  advanced  against  the  tablet 
method,  viz.,  that  it  does  not  allow  of  modification  of  the  suprarenin 
admixture,  is  untenable  according  to  Braun's  statement  that  "the 
dosage  of  suprarenin  in  the  infinitesimal  doses  in  which  it  is  employed 
in  local  anesthesia  is  fairly  immaterial.  These  greatly  diluted  doses 
must  be  regarded  as  absolutely  innocuous,  provided  a  pure  prepara- 
tion and  fresh,  unaltered  solutions  are  used." 

Following  the  Miinster  meeting  I  have  made  thorough  experiments 
in  order  to  ascertain  whether  Seidel's  method  of  making  a  solution 
is  superior  to  the  tablet  method  or  not,  and  I  have  come  to  the  con- 
clusion that  the  advantages  of  adding  the  suprarenin  to  every  solution 
made  are  defeated  by  the  disadvantages  inherent  in  this  procedure. 
In  the  first  place,  it  is  very  difficult  in  daily  practice  to  draw  the  supra- 
renin solution  into  a  pipette  under  all  necessary  precautions ;  moreover, 
the  suprarenin  becomes  easily  contaminated  by  the  influence  of  air, 
light,  temperature,  dust,  etc.,  every  time  a  few  drops  are  poured  out. 
Chemists  themselves  admit  that  "the  stability  of  suprarenin  solution 
depends  upon  a  great  many  contingencies  which  cannot  be  avoided 
or  controlled  even  with  utmost  care.  Suprarenin  in  solution  does  not 
keep  any  length  of  time,  but  in  dry  tablet  form,  even  in  combination 
with  novocain,  it  remains  unaltered  for  a  long  time."     (Braun.) 

For  these   reasons  it  does   not  seem   advisable   to  adopt  Seidel's 


60  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

method  of  preparing  the  solution  in  private  practice,  because  it  permits 
of  new  sources  of  error.  Braun's  perfect  results  with  the  tablet  method 
in  major  surgery  fully  justify  its  adoption  in  dentistry.  Following 
Braun's  lead,  and  convinced  by  our  own  experiences,  we  must  pro- 
nounce the  solution  made  from  tablets  as  the  best  and  safest  procedure 
for  dental  work.  If  we  wish  to  individualize  our  dosage,  we  simply 
add  2  tablets  E  to  3  c.c.  or  4  tablets  to  5  c.c.  of  Ringer  solution,  instead 
of  adding  i  tablet  E  to  i  c.c.  of  Ringer  solution.  Since,  in  doing  so, 
we  simultaneously  reduce  the  dosage  of  novocain,  we  lessen  the  toxicity 
of  the  whole  solution,  and  are  in  position  to  avoid  failures  or  untoward 
secondary  effects  while  retaining  the  full  anesthetic  power  of  the 
solution.  In  all  cases  where  an  untoward  effect  of  the  injection  is 
feared,  as  in  delicate  and  anemic  patients  who  are  subject  to  fainting, 
the  stasis  bandage  illustrated  in  Fig.  9  can  be  advantageously  em- 
ployed. In  thousands  of  cases  of  this  kind  this  stasis  has  prevented 
untoward  symptoms.  I  also  fully  agree  with  Braun  that  as  long  as 
the  large  doses  of  suprarenin  which  are  employed  in  major  surgery, 
and  in  comparison  with  which  our  dental  doses  are  infinitesimally 
small,  have  not  produced  any  alarming  symptoms,  as  a  perusal  of  the 
literature  on  this  subject  has  shown,  there  is  no  reason  to  demand  a 
modification  of  the  suprarenin  admixture  in  every  individual  case. 

To  make  absolutely  sure,  I  have  made  additional  practical  com- 
parisons to  ascertain  whether  the  reduction  of  the  suprarenin  by 
dissolving  the  tablets  in  a  quantity  of  liquid  larger  than  normally 
intended,  is  really  too  great,  as  Seidel  maintains,  and  have  found  that 
this  is  not  the  case.  Aside  from  theoretical  considerations,  practical 
experience  has  proved  that  the  diluted  tablet  solution  is  fully  efficient, 
as  can  be  verified  by  controls.  In  order  also  to  test  Braun's  contention 
that  the  doses  of  suprarenal  extract  employed  for  dental  purposes 
are  so  small  as  to  be  innocuous,  I  have  employed  1.5  per  cent,  and  2 
per  cent,  novocain  tablets  in  Ringer  solution,  without  reducing  the 
suprarenin  dosage,  in  about  500  cases  of  patients  with  delicate  consti- 
tution, serious  heart  disease,  arteriosclerosis,  etc.,  and  have  not  observed 
one  single  case  of  intoxication.  In  these  cases,  to  be  sure,  the  stasis 
bandage  was  employed. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  61 

After  the  investigations  described,  I  fully  agree  with  Braun  that 
as  long  as  the  solution,  and  the  injection,  etc.,  are  made  correctly, 
the  hair-splitting  finesses  which  Seidel  indulges  in  are  of  no  practical 
significance  for  dentists.  In  short,  the  tablet  method  as  advocated 
by  Braun  is  superior  to  all  others  and  most  suitable  for  dental  prac- 
tice, where  further  modifications  of  the  solutions  are  uncalled  for, 
and  will  merely  complicate  matters. 

The  Solution,  its  Composition  and  Preparation. — ^Various  concen- 
trations of  novocain  solutions,  viz.,  from  0.5  to  2  per  cent.,  have  been 
recommended  for  dental  purposes.  Personally,  I  have  contended  for 
years  that  it  is  best  to  keep  the  concentration  of  the  novocain  as  well 
as  the  suprarenin  as  low  as  has  been  found  practical  in  the  large 
average  of  cases.  In  delicate  adults  and  in  children  we  have  had 
excellent  results  with  0.5  per  cent,  novocain  solutions,  and  I  am  still 
convinced  that  the  1.5  per  cent,  novocain-suprarenin  solution  is  suc- 
cessful in  all  ordinary  and  even  in  the  most  complicated  cases.  This 
is  also  attested  to  by  the  recent  reports  of  Braun,  AdlofT,  and  others, 
who  find  a  i  per  cent,  solution  always  satisfactory,  and  warmly 
recommend  this  concentration.  To  cite  Braun:  "I  admit  that  in 
minor  ambulatory  surgery  it  is  desirable  to  have  only  one  solution 
with  which  every  operation  can  be  made,  and  that  is  the  i  per  cent 
solution." 

If  I  have,  nevertheless,  advocated  the  2  per  cent,  concentration, 
this  was  done  because  it  is  not  the  concentration  of  the  novocain  so 
much  which  determines  the  toxicity  of  the  solution  as  the  suprarenin. 
The  2  per  cent,  solution  can  be  generally  recommended  for  dental 
practice  without  hesitation,  so  long  as  it  is  understood  that  the  con- 
centration limit  of  2  per  cent,  must  never  be  exceeded,  while,  with 
some  experience,  a  practitioner  may  find  it  practical  to  reduce  the 
dosage.  I  would  certainly  make  a  plea  that  the  advocates  of  the  2 
per  cent,  solution  should  not  refrain  from  trying  out  the  i  per  cent, 
and  1.5  per  cent,  solutions,  which  they  will  surely  find  fully  success- 
ful after  some  trials.  The  efficacy  of  the  solution  depends  upon  its 
proper  composition,  perfect  isotonia,  and  sterilization  before  injection. 
The   isotonia  of  a  solution   and   its  optimum   rapidity  of  absorption 


62  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

in  the  tissues  are  insured  by  the  addition  of  from  0.65  to  0.92  per 
cent,  chemically  pure  sodium  chlorid.  For  the  1.5  per  cent,  novocain 
solution,  a  NaCl  content  of  0.7  per  cent,  seems  best  indicated. 

Addition  of  Calcium  Salts. — Professor  Giirber,  Director  of  the 
Pharmacologic  Institute  of  Marburg  University,  has  for  years  been 
making  experiments  regarding  the  behavior  of  calcium  salts  added 
to  the  injected  solutions.  Upon  his  instigation  chiefly  I  have  sub- 
stituted a  modified  Ringer  solution  for  the  normal  salt  solution,  and 
clinical  evidence  has  shown  that  the  addition  of  calcium  salts  is  abso- 
lutely innocuous,  and  most  favorably  influences  the  process  of  absorp- 
tion of  the  solution  in  the  tissues.  In  this  respect  a  considerable 
improvement  has  been  noted  as  compared  with  simple  sodium 
chlorid  solution,  and  further  tests  have  suggested  also  a  theoretical 
proof  of  this  observation.  Calcium  undoubtedly  has  an  important 
function.  A  trace  of  calcium  suffices,  for  instance,  to  increase  the 
vital  function  of  the  leukocytes,  the  salts  of  calcium  being  of  prime 
importance  in  phagocytosis  and  in  resistance  to  infectious  diseases. 

Calcium  chlorid  0.05  per  cent,  produces  a  stimulation  in  phago- 
cytosis of  about  22  per  cent.,  o.i  per  cent.  CaCL  one  of  45  per  cent., 
while  0.25  per  cent.  CaCl2  decreases  again  the  phagocytic  action  of 
the  leukocytes. 

Owing  to  its  easy  oxidability,  calcium  does  not  occur  free  in  nature, 
but  in  the  form  of  calcium  ions  it  probably  plays  an  essential  part  in 
the  chemical  and  electrolytic  processes  in  the  organism.  Its  oxid,  again 
owing  to  its  great  affinity  for  acids,  occurs  in  the  body  only  in  form 
of  a  salt,  while  the  calcium  salts  in  turn  seem  to  combine  with  various 
proteids. 

Of  special  significance  in  this  question  of  the  action  of  calcium 
salts  upon  the  cells  and  tissues  is  the  fact  that  besides  the  calcium 
ion  no  other  substance  is  capable  of  increasing  the  phagocytic  action 
of  the  leukocytes.  Hamburger  has  thus  ascertained  the  following 
phenomena: 

I.  If  the  heart  of  a  turtle,  which  in  a  moist  medium  will  continue 
to  beat  for  a  long  time,  is  immersed  in  a  pure  sodium  chlorid  solution, 
the   beats   cease   immediately.     Sodium   chlorid,   therefore,   evidently 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  63 

exerts  a  toxic  action  upon  the  heart.  If,  however,  a  minute  trace  of 
calcium  is  added,  the  heart  at  once  begins  to  beat  again. 

2.  If  a  trace  of  calcium  is  added  to  a  sodium  chlorid  infusion  the 
collapsing  human  heart  almost  immediately  begins  to  work  more 
vigorously,  and  the  blood-pressure  rises  higher  than  it  would  if  simply 
a  sodium  chlorid  infusion  were  used. 

The  presence  of  calcium  ions  counteracts  the  toxic  influence  of 
pure  sodium  chlorid  solution  and  stimulates  the  heart  action.  From 
these  observations  internal  medicine  has  adopted  the  practice  of 
adding  calcium  to  every  infusion. 

Although  pure  sodium  chlorid  solution  apparently  does  not  exert 
as  pronounced  a  toxic  action  upon  the  phagocytes  as  upon  the  heart 
and  intestines,  nevertheless  a  slightly  toxic  untoward  effect  is  demon- 
strable, according  to  Sticker,  the  phagocytic  power  of  the  leukocytes 
being  impaired.  Calcium  therapy  also  plays  a  surprisingly  important 
role  in  infectious  diseases,  since  calcium  ions,  if  added  to  a  vaccine, 
have  a  stimulating  action  upon  the  functions  of  the  heart  and  the 
leukocytes,  as  for  instance  in  diphtheria,  pneumonia,  and  especially 
in  tuberculosis.  It  has  long  been  known  that  workers  at  lime-kilns 
who  continually  inhale  liberal  quantities  of  dust  from  burned  and 
slaked  lime  rarely  suffer  from  tuberculosis.  In  febrile  conditions, 
the  antipyretics  administered  by  no  means  counteract  the  usually 
concomitant  diminution  in  the  alkalinity  of  the  blood  (Klemperer), 
but  here  again  calcium  therapy  is  employed  to  greatest  advantage, 
being  a  purely  physiologic,  hence  natural,  method  of  treatment  free 
from  untoward  secondary  effects. 

In  connection  with  these  findings,  the  Viennese  scientists,  Chiari 
and  Januschke,  have  ascertained  that  soluble,  neutral  calcium  salts 
exert  a  remarkably  antiphlogistic  action.  According  to  Leo  it  seems 
certain  that  "the  calcium  ions  in  the  human  organism  serve  as  solidi- 
fying agents,  and  their  presence  is  indispensable  especially  in  the 
enzymotic  processes  leading  to  the  coagulation  of  fibrin  and  casein. 
The  observation  that  only  infinitesimal  quantities  of  calcium  are 
necessary  to  produce  the  coagulation  even  of  large  quantities  of  blood 
or  milk   seems   to   explain   why   such   minimal   quantities   of  calcium 


64         MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

as  are  conducted  to  inflamed  tissues  by  the  circulation  following 
subcutaneous  injection  can  exert  such  a  marked  effect." 

Leo  has  made  control  tests  of  the  antiphlogistic  properties  of 
calcium  salts  in  pneumococcic  and  other  infections,  all  of  which  proved 
positive.  The  selection  of  the  bacteria  in  these  tests  was  immaterial, 
"since  the  action  of  the  calcium  salts  is  not  directed  against  the  phlo- 
gogenic  organisms  themselves,  but  these  salts  serve  to  strengthen 
the  resistance  of  the  tissues  against  the  influence  of  phlogogenic 
organisms  without  influencing  these  directly."  Leo  has  shown  that 
small  quantities  of  calcium  chlorid,  viz.,  i  c.c.  of  a  2.5  per  cent,  solu- 
tion, can  be  injected  hypodermically  in  man  without  producing  local 
or  systemic  lesions.  In  inflammations  of  mucous  membranes,  as  in 
the  mouth,  Leo  recommends  rinsing  with  2  per  cent,  calcium  solu- 
tion. 

From  the  above  brief  account,  the  importance  of  calcium  salts 
in  our  special  field  becomes  evident.  It  is  only  natural  that  we  should 
utilize  the  wonderful  properties  of  the  calcium  ions  in  the  hypodermic 
injection  of  anesthetics  in  order  to  limit  to  a  minimum  the  possible 
sequelae  of  injections.  In  every  injection  we  produce  a  tissue  lesion 
by  the  insertion  of  the  needle;  the  tissue  itself  is  inundated  with  a 
foreign  fluid,  and  a  temporary  change  is  produced  in  the  metabolism 
by  the  elimination  of  the  sensory  organs.  Under  normal  conditions, 
and  if  all  necessary  precautions  have  been  taken,  this  condition  of 
the  tissue  is  usually,  though  not  always,  tolerated  with  impunity, 
the  solution  is  fully  absorbed,  and  the  temporarily  altered  tissue 
quickly  resumes  its  normal  function.  In  cases  of  acute  inflammation 
or  suppuration,  however,  the  elimination  of  sensation  is  not  tolerated 
so  indifferently,  absorption  seems  retarded,  edema  forms  frequently, 
and  even  after-pain  may  occur.  In  such  cases  the  sodium  chlorid 
base  as  formerly  employed  seems  to  approach  the  ideal,  though  even 
then  the  untoward  secondary  effects  described  could  not  always  be 
entirely  avoided  despite  perfect  technique,  solution,  and  diagnosis. 
The  calcium  chlorid  base,  however,  as  we  are  now  employing  it  in  the 
form  of  the  Ringer  solution,  has  proved  superior  to  the  pure  sodium 
chlorid  base,  in  fact,  ideal  for  local  injection.     The  calcium  salts  in 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  65 

combination  with  the  other  salts  insure  surprisingly  perfect  absorp- 
tion even  in  the  most  difficult  cases,  increase  the  penetrating  action, 
and,  in  surgical  cases,  contribute  materially  to  rapid  and  uneventful 
wound  healing.  Rinsing  with  2  per  cent,  calcium  chlorid  solutions 
favorably  influences  and  accelerates  healing  in  the  oral  mucosa;  lime 
water  should,  therefore,  be  given  a  thorough  trial  in  all  inflammatory 
conditions  of  the  mouth.  The  advantages  of  the  calcium  chlorid  base 
are  so  convincing,  and  clinically  so  evident,  that  it  is  surprising 
the  Ringer  base  has  not  long  been  tried  in  connection  with  local 
injections,  considering  the  fact  that  for  quite  some  time  all  infusions 
have  been  prepared  with  an  admixture  of  calcium.  Why  should  we 
cling  to  the  time-honored  "physiologic  salt  solution"  in  interventions 
which  necessitate  the  direct  inundating  of  the  tissues  with  foreign  solu- 
tions? Everyone  will  agree  that  the  sodium  chlorid  solution  is  by 
no  means  cognate  to  the  cell  and  strictly  "physiologic,"  since  it 
lacks  an  important  constituent  which  the  cell  requires  for  normal 
metabolism.  These  constituents — namely,  calcium  chlorid,  potassium 
chlorid  and  sodium  bicarbonate — have  been  determined  by  Ringer 
several  years  ago.  Of  these  salts  I  have  omitted  the  sodium  bicar- 
bonate as  being  an  extremely  unstable  body.  This  omission  is  in  no 
way  detrimental  to  the  effect  of  the  solution,  because,  for  the  improve- 
ment of  absorption,  calcium  chlorid  is  of  chief  importance. 

Since  the  summer  of  1912  we  have  combined  all  imaginable  per- 
centages of  local  anesthetics  with  Ringer  solution,  and  have  noted  in 
all  cases  an  improvement  both  in  the  anesthetic  action  and  the  after- 
efl^ects  as  compared  with  pure  sodium  chlorid  solutions  of  these  anes- 
thetics. In  severe  purulent  conditions,  in  which  the  sodium  chlorid 
solution  used  to  produce  edema,  after-pain,  and  disturbances  in  the 
healing  process,  all  secondary  effects  were  either  surprisingly  trivial  or 
entirely  absent.  In  simple  injections,  as  a  rule,  no  untoward  sequelae 
were  observed. 

It  seems  questionable  whether  the  addition  of  sodium  bicarbonate 
and  potassium  sulphate,  which  have  been  advocated  chiefly  for  the  pur- 
pose of  better  utilization  of  the  free  novocain  base  and  reduction  in 
the  concentration  of  novocain,  will  ever  prove  to  be  practical.  As 
.5 


66  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

compared  with  calcium  chlorid  additions,  these  substances  are  inchned 
to  have  an  irritating  action  upon  the  tissues. 

From  these  considerations  I  would  advocate  a  novocain  solution 
of  the  following  composition: 

Novocain 1 .0  or  i  .5  or  2.0 

Sodium  chlorid         0.5 

Calcium  chlorid 0.04 

Potassium  chlorid 0.02 

Sterile  aqua  destillata         loo.o 

Synthetic  suprarenin  (i  to  1000)         0.002 

Fig.  I 


Flask  for  Ringer  solution  and  porcelain  cup  for  preparing  and  sterilizing  novocain-suprarenin 

solution. 


Preparation  of  the  Solution. — The  solution  is  best  made  from 
novocain-suprarenin  tablets  and  a  Ringer  stock  solution.  The  instru- 
mentarium  required  for  this  purpose  consists  of  a  stock  flask  (see  Figs. 
I  and  11),  which  serves  for  the  preservation  and  gradual  consumption 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  67 

of  the  Ringer  solution  under  sterile  conditions,  and  a  small  test-tube, 
graduated  to  8  c.c,  both  made  of  Jena  glass.  The  test-tube  rests 
upon  a  secure  wooden  stand  and  is  held  with  a  pair  of  tweezers  while 
boiling  the  solution.  The  stock  flask  holds  50  c.c,  and  is  constructed 
in  such  a  manner  that,  without  removing  the  glass  stopper,  the 
desired  quantity  can  be  poured  off  through  a  tapering  glass  nozzle, 
air  being  admitted  through  a  small  side  opening  which  is  sealed  with 
a  wad  of  cotton.  After  this  stock  flask,  together  with  the  rest  of  the 
instrumentarium,  has  been  sterilized  in  boiling  distilled  water  for  ten 
minutes,  it  is  filled  with  the  following  modified  Ringer  solution: 

Sodium  chlorid         0.5 

Calcium  chlorid o. 04 

Potassium  chlorid o. 02 

Aqua  destillata         100. o 

The  correct  proportions  of  this  modified  Ringer  solution  are  best 
insured  if  the  operator  makes  it  himself  from  the  Ringer  tablets  manu- 
factured by  a  few  reliable  diug  firms,  5  of  these  tablets  dissolved  in 
50  c.c.  of  aqua  destillata  giving  the  correct  solution. 

The  filled  stock  flask  is  closed  and  its  contents  are  boiled  for  ten 
minutes  in  a  distilled  water  bath,  preferably  in  a  small  electric  boiler 
(see  Fig.  2)  which  is  best  suited  for  disinfection  in  local  anesthesia,  and 
must  always  be  fed  with  distilled  water.  In  order  to  prevent  the  stock 
flask  from  breaking  during  the  process  of  sterilization,  it  is  best  to  tie 
around  it  a  sterile  mouth  napkin.  Electric  sterilizers,  which  are  so  con- 
structed that  the  heating  element  dips  into  the  water,  are  unsuitable 
for  this  purpose.  In  regard  to  the  use  of  distilled  water,  Riethmiiller^ 
writes : 

"It  goes  without  saying  that  only  aqua  destillata  should  be  used 
in  making  up  a  solution.  Boiled  water  is  by  no  means  sterile;  more- 
over, it  may  contain  quantities  of  alkalies,  these  varying  in  different 
districts,  which  detrimentally  affect  the  solution,  as  will  be  indicated 
by  a  pink  or  rose  discoloration.  Even  the  aqua  destillata  as  bought 
in  pharmacies  is  by  no  means  reliable,  as  everyone  familiar  with  the 
slipshod  methods  by  which  it  is  made — usually  in  the  darkest  spare 

'  Dental  Cosmos,  Feljruary,  1913. 


68 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


corner,  and  frequently  by  none  too  careful  or  skilled  clerks — knows 
very  well.  It  frequently  contains  bacteria  that  have  been  introduced 
from  the  air  or  the  dust  collected  on  the  large  bottle  in  which  it  is 
kept,  and  on  close  scrutiny  is  often  found  to  have  particles  of  dust, 
filter  paper,  or  even  hair,  suspended  in  it.  The  acquisition  of  a  small 
filter  apparatus  will  therefore  prove  a  boon  to  the  conscientious  oper- 
ator, and  in  a  busy  and  clean  practice  will  soon  pay  for  the  initial 
investment,  especially  since  aqua  destillata  must  be  used  for  the 
sterilization  of  the  instrumentarium  employed  in  connection  with 
local  anesthesia. 

Fig.  2 


Electric  sterilizer. 


"It  is  a  fact  known  to  every  chemist  that  glass,  which  is  more  or 
less  strongly  of  an  alkaline  nature,  is  dissolved  by  cold  and  hot  water, 
and  these  traces  of  alkali,  however  minute,  seriously  affect  the  stability 
of  suprarenal  preparations.  Some  operators  for  this  reason  employ 
only  the  scientifically  manufactured  brown  non-alkaline  glassware 
of  the  Jena  glass  works.  How  sensitive  to  alkalis  the  suprarenal 
preparations  are  is  strikingly  illustrated  by  a  report  of  Dr.  E.  Paul.^ 
He  found  that,  four  weeks  after  purchase,  the  contents  of  an  unopened 

'  Deutsch.  Zahnarztliche  Woch.,  February  lo,  1912. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  69 

bottle  of  suprarenin  manufactured  by  a  reputable  drug  firm  had 
become  turbid. 

"For  reasons  similar  to  those  given  in  favor  of  the  preparation  of 
aqua  destillata  by  the  operator  himself,  the  purchase  of  prepared 
Ringer  solution  is  undesirable.  The  purchased  product  often  contains 
impure  drugs  in  incorrect  dosage  and  slight  traces  of  soda.  A  purchased 
Ringer  solution  should  always  be  tested  for  alkaline  traces;  if  present, 
the  alkalis  must  be  neutralized  by  the  addition  of  one  drop  of  one- 
tenth  dilute  hydrochloric  acid,  which  compensates  at  the  same  time  for 
the  alkalinity  of  ordinary  glass  containers  and  prevents  the  catalysis 
of  oxygen  in  the  anesthetic  solution,  either  of  which  unfavorably 
influences  the  suprarenin." 

The  Ringer  solution  is  best  filtered  into  the  stock  flask  through 
sterile  filter  paper.  All  the  salts  in  the  solution  must  be  chemically 
pure.  The  quantity  of  Ringer  solution  required  in  a  given  case  is 
poured  out  into  the  previously  sterilized  test-tube  of  Jena  glass  after 
removing  the  little  glass  hood  from  the  nozzle.  This  method  prevents 
the  invasion  of  microorganisms  from  the  surrounding  air  almost 
entirely,  and  insures  the  sterility  of  the  solution  for  a  longer  period  of 
time.  The  poured-off  quantity  should  always  be  slightly  greater  than 
is  absolutely  needed,  because  in  boiling  a  small  fraction  of  the  solution 
is  lost  by  evaporation.  The  test-tube  is  grasped  with  the  tweezers, 
and  the  Ringer  solution  boiled  for  a  few  seconds  over  an  alcohol  flame. 
The  use  of  a  Bunsen  gas  burner  is  not  advisable,  as  the  combustion 
is  not  always  perfect,  and  undesirable  particles  of  soot  are  carried 
into  the  solution  and  deposited  upon  the  iridio-platinum  needle  in 
sterilizing. 

Into  the  hot  Ringer  solution,  the  novocain-suprarenin  tablets  are 
thrown  with  sterile  pincers,  i  tablet  E  in  i  c.c.  of  solution  giving  a  2 
per  cent.,  i  tablet  G  in  i  c.c.  of  Ringer  solution  giving  a  1.5  per  cent, 
novocain-suprarenin  solution.  After  adding  the  necessary  number 
of  tablets,  the  solution  is  once  more  raised  to  boiling-point,  and  the 
hot,  closed  test-tube  is  set  upon  the  wooden  stand  at  an  angle  of  45 
degrees.  The  sterile  syringe,  through  which  hot  distilled  water  has 
been  drawn  several  times,  can  now  be  conveniently  filled  by  drawing 


70 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


up  the  solution  through  the  iridio-platinum  needle,  which  has  pre- 
viously been  passed  through  the  alcohol  flame.  The  solution,  which 
has  in  the  meantime  cooled  to  body  temperature,  is  at  once  injected. 

The  Hoechst  Farbwerke  Co.  are  now  marketing  small  graduated 
porcelain  cups  of  two  sizes,  holding  3  and  10  c.c.  of  solution  respec- 
tively, with  convenient  metal  stands  and  handles,  which  are  extremely 
practical  for  preparing  the  tablet  solution,  and  appreciably  simplify 
the  instrumentarium  (see  Fig.  i). 

In  order  still  further  to  reduce  the  possibility  of  introduction  of 
microorganisms  from  any  source,  the  editor  has  constructed  a  stock 
flask  for  the  Ringer  solution,  (see  Fig.  11)  and  has  otherwise  modified 
the  Fischer  instrumentarium  as  described  in  detail  on  page  91. 

If  novocaln-suprarenin  solution  is  prepared  by  the  procedure 
above  indicated,  it  will  always  be  fresh  and  crystal  clear,  possess 
body  temperature,  and  fulfill  all  reasonable  requirements  of  an  anes- 
thetic solution.  If  one  wishes  to  reduce  the  concentration,  2  instead 
of  3  tablets  E  in  3  c.c,  or  4  tablets  E  in  5  c.c,  or,  for  still  greater  reduc- 
tion, 2  tablets  G  in  3  c.c  of  Ringer  solution  are  employed.  The  ease 
with  which  solutions  can  be  modified  according  to  the  operator's 
judgment  and  the  requirements  of  the  case,  is  demonstrated  in  the 
affixed  table: 

Table  of  Modified  Solutions. 


Quantit}^  of  Ringer  solution. 

2  c.c.  of  Ringer  solution 

3  c.c.     " 

2  c.c.      "             " 

Number  of  tablets. 

1  tablet    E 

2  tablets  G 
I  tablet    G 

To  make  a 
concentration  of 
1 .0  per  cent. 
1 .0        " 
0.75      " 

3  c.c.      " 

I       "       E 

0.7        " 

3  c.c.     " 

I       "       G 

0.5 

4  c.c.     "            " 

I       "       E 

0.5        " 

As  a  precaution,  freshly  made  solutions  should  always  be  protected 
immediately  from  light  by  a  cover  of  ruby-colored  glass,  unless  the 
entire  quantity  of  solution  is  used  at  once.  A  solution  which  after 
standing  for  more  than  thirty  minutes  is  no  longer  entirely  clear 
should  never  be  used.  Even  the  slightest  discoloration  indicates 
decomposition  of  the  suprarenin  and  renders  unsafe  the  sequelae, 
though  not  the  effect  of  the  injection.     It  is  far  better  to  make  several 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  71 

fresh  solutions  than  to  use  one  that  has  been  standing  for  some  time. 
We  always  use  up  the  quantity  calculated  for  a  case,  and  prefer  to 
make  several  fresh  solutions  rather  than  employ  a  stock  solution. 
This  precaution  has  been  fully  justified  by  the  invariability  in  the 
certainty  and  safety  of  our  results. 

Factors  in  a  Successful  Injection. — Failures  are  not  due  to  the 
solution  only.  As  we  have  seen,  to  render  an  injection  perfect  in 
all  its  phases  many  factors  are  to  be  considered  individually.  To 
recapitulate  briefly:  solution,  glassware,  syringe,  needles  and  field  of 
operation  must  be  absolutely  sterile;  the  solution,  moreover,  must 
be  of  optimum  composition;  the  normal  and  pathological  anatomy  of 
the  field  of  operation  must  be  given  due  consideration ;  and  last  but  not 
least,  the  technical  execution  of  the  injection  must  be  governed  in 
every  case  by  a  correct  interpretation  of  the  conditions  presented. 
In  addition,  the  physical  constitution  of  the  individual  patient  must 
be  subjected  to  a  rigid  examination.  Is  it  a  wonder,  then,  that  the 
criticisms  of  local  anesthesia  vary  so  greatly,  when,  owing  to  the 
complicated  nature  of  the  technique — which,  however,  after  some 
practice  becomes  simple  routine — the  neglect  of  one  single  postulate 
sufiices  to  impair  the  desired  effect  and  to  produce  partial  or  total 
failure,  which  unskilled  and  careless  operators  are  usually  too  prone 
to  attribute  to  the  anesthetic  solution  itself? 

Compound  Tablets  of  Novocain-suprarenin  and  Sodium  Chlorid 
Contra-indicated. — For  the  purpose  of  simplifying  the  preparation 
of  isotonic  solutions,  several  drug  houses  are  marketing  compound 
tablets  of  novocain,  suprarenin,  and  sodium  chlorid.  In  tests  of  a 
great  many  of  these  tablets  from  different  manufacturers,  Rieth- 
miiller  has  found  that  they  give  discolored  solutions  within  a  very 
short  time  after  purchase,  especially  when  the  tube  has  once  been 
broached,  proving  that  the  composition  of  novocain-suprarenin  and 
sodium  chlorid  is  very  unstable. 

Mixtures  of  Novocain  and  Peptones,  and  Novocain  and  Hydrogen 
Dioxid  Contra-indicated. — Experiments  have  been  conducted  by  Fichot 
in    collaboration    with    Hillard^   with    combinations   of   novocain    with 

•  Dental  Cosmos,  January,  1913,  p.  105. 


72  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

from  2  to  10  per  cent,  of  Byla's  peptone,  for  which  more  rapid  anes- 
thesia, quicker  cicatrization,  and  absence  of  all  idiosyncratic  symptoms 
are  claimed.  These  claims,  which  have  not  yet  been  substantiated, 
are  counteracted  by  the  fact  that  no  guaranty  can  be  had  regarding 
the  sterile  character  of  peptones,  which  are  an  extremely  favorable 
culture  medium  for  bacteria;  at  the  same  time,  sterilization  of  the 
novocain-peptone  mixture  by  boiling  is  impossible.  While  it  is  true 
that  a  few  cases  of  idiosyncratic  sequelae  following  novocain-suprarenin 
injection  have  been  reported,  yet  they  are  far  less  numerous  than 
with  cocain,  and  the  symptoms  are  considerably  less  severe  and 
alarming. 

The  objections  to  the  combination  of  novocain  with  five-volume 
solutions  of  hydrogen  dioxid,  as  indicated  by  Marmouget  of  Bordeaux 
and  advocated  by  Mahe  and  Vanel'  of  Paris,  are  even  greater,  owing 
to  the  unstable  and  treacherous  nature  of  hydrogen  dioxid,  the  use 
of  which  is  becoming  more  and  more  restricted  in  medical  and  dental 
practice.  The  advocates  of  this  method  themselves,  who  have  made 
only  a  very  limited  number  of  practical  tests,  do  not  seem  to  be  over- 
confident, and  state  that  for  deeper  injections,  and  especially  for 
conductive  anesthesia,  the  combination  of  novocain  with  suprarenin 
is  far  preferable. 

Braun's  Experiences  with  Novocain  and  its  Solutions. — The  most 
enthusiastic  champion  of  novocain  solution,  H.  Braun,^  of  Zwickau, 
published  in  19 lo  a  comprehensive  treatise  on  the  employment  of 
novocain  in  surgery.  From  this  work  it  appears  plainly  that  novocain 
is  most  extensively  used  in  major  surgery,  especially  in  small  doses, 
viz.,  in  0.5  per  cent,  and  i  per  cent,  solutions. 

The  statements  made  in  the  recently  published  third  edition  of 
his  text-book  fully  coincide  in  all  essential  details  with  our  own  experi- 
ences. This  thoroughly  revised  new  edition  shows  especially  that 
Braun,  in  contradistinction  to  certain  dental  writers,  does  not  consider 
advisable  any  essential  modifications  in  the  preparation  of  the  solution 

1  Dental  Cosmos,  January,  1914,  p.  124. 

2  Beitrage   zur   klinischen    Chirurgie,    1910;    also    F.    Peuckert,    Further    Contributions    to   the 
Application  of  Local  Anesthesia  and  Suprarenin  Anemia. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  73 

and  the  technique  of  its  injection.  It  is  most  gratifying  that  these 
views  of  the  past-master  in  local  anesthesia  can  be  maintained 
unmodified  in  our  dental  practice. 

Braun  has  indicated  four  different  solutions,  the  weakest  being 
0.25  per  cent.,  the  strongest,  2  per  cent,  novocain.  Solutions  i  (0.25 
per  cent.)  and  2  (0.5  per  cent.)  are  employed  when  thick  layers  and 
extensive  areas  of  tissue  are  to  be  infiltrated.  Solutions  3  (i  per  cent.) 
and  4  (2  per  cent.),  which  contain  correspondingly  more  suprarenin, 
serve  for  conductive  anesthesia  proper.  Braun,  for  the  sake  of  sim- 
plicity, employs  as  few  solutions  as  possible,  and  preferably  only 
one  form  of  tablets.  He  also  endeavors  to  restrict  the  use  of  the 
high  per  cent,  solutions  (3  and  4)  as  much  as  possible.  "We  have 
generally  substituted  the  i  per  cent,  for  the  2  per  cent,  solution, 
injecting  a  little  more  of  the  former  than  we  employed  originally." 
Hence  Braun  uses  in  the  main  only  two,  namely,  the  0.5  per  cent, 
and  the  i  per  cent,  novocain  solutions.  "The  i  per  cent,  novocain 
solution  suffices  for  tooth  extractions,  also  without  exception  for 
the  conductive  blocking  of  large  nerve  trunks." 

Application  of  Local  Anesthesia  in  Surgery. — The  wide  adoption 
of  local  anesthesia  in  surgery,  promoted  by  a  suitable  technique  of 
injection,  is  characterized  by  the  following  passages  in  Braun's  report: 
"Of  10  complicated  cases  of  fracture  of  the  skull  two  were  operated 
upon  under  local  anesthesia;  also  two  skull  trepanations  were  per- 
formed under  local  anesthesia  for  suspected  abscess  of  the  brain,  and 
in  one  case  for  removal  of  a  bullet  from  the  brain.  Peripheral  injection 
of  the  field  of  operation  with  0.5  per  cent,  novocain-suprarenin  solution 
is  a  superior  means  of  reducing  hemorrhage  in  cranial  operations. 
It  supersedes  all  other  aids  recommended  for  this  purpose,  is  much 
more  effective,  and  permits  of  the  performance  of  cranial  and  cerebral 
operations  with  a  minimum  of  hemorrhage  and  anesthesia.  All  these 
advantages  cannot  be  underestimated,  nor  can  they  be  attained  by 
any  other  similar  procedure. 

"  One  operation  which  we  now  perform  exclusively  under  local 
anesthesia  is  that  for  empyema  of  the  frontal  and  the  ethmoidal  sinuses. 
It  is  possible  to  make  all  operations  on  the  frontal  sinus,  the  chiselling 


74  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

away  of  the  entire  anterior  and  inferior  walls,  Kilian's  radical  opera- 
tion, Earth's  operation,  opening  into  the  ethmoidal  sinuses,  probably 
also  into  the  sphenoidal  sinuses.  The  field  of  operation  is  completely 
anesthetized  and  so  anemic  that  the  operation  can  be  carried  out 
much  more  easily,  neatly,  and  rapidly  than  under  general  anesthesia. 

''We  prefer  local  anesthesia  even  in  resection  of  the  maxilla,  since 
the  admixture  of  suprarenin  sufficiently  guarantees  the  intensity  and 
duration  of  the  anesthesia.  By  inducing  scopolamin  slumber  we  are 
enabled  to  do  away  also  with  the  unfavorable  psychic  impression  of 
the  operation  upon  the  patient. 

"The  blocking  of  the  superior  maxillary  nerve  in  the  sphenomaxillary 
fossa  has  been  accomplished  in  5  cases  successfully  and  without  any 
difficulty.  The  point  of  injection  is  found,  upon  palpation,  to  lie 
closely  posterior  to  the  inferior  process  of  the  malar  bone,  whence  the 
needle  is  advanced  inwardly  and  upwardly,  its  point  reaching  the 
maxillary  tuberosity  immediately  back  of  the  zygoma.  Gently  groping 
along  the  surface  of  the  tuberosity,  the  needle  easily  advances,  and, 
in  a  depth  of  from  5  to  6  cm.  meets  the  superior  maxillary  nerve  in  the 
sphenomaxillary  fossa.  The  patient  immediately  feels  a  slight  pain 
radiating  into  the  maxilla.  The  syringe  is  then  attached  to  the  needle, 
and  under  slight  backward  and  forward  motion  of  the  needle  from  5 
to  10  c.c.  of  a  I  per  cent,  novocain  solution  are  injected.  The  injec- 
tion can  be  executed  easily  and  safely.  Anesthesia  in  the  whole  area 
of  the  superior  maxillary  nerve  ensued  in  all  cases  almost  immediately 
after  the  injection. 

"Of  7  cases  of  resection  of  the  maxilla,  2  had  to  be  subjected  to 
general  anesthesia  owing  to  excessive  extension  of  the  tumor.  The 
other  5  were  operated  upon  under  local  anesthesia. 

"The  course  of  operation  under  local  anesthesia  is  quite  different 
from  the  usual.  No  interruptions  of  the  operation  as  needed  for  the 
continuance  of  general  anesthesia  are  required,  and  the  operation  can 
be  completed  in  a  minimum  of  time.  Owing  to  the  anemia  from  the 
suprarenin,  the  continual  inundation  of  the  field  of  operation  with 
blood  is  avoided,  and  the  few  bleeding  vessels  can  be  quickly  and 
conveniently    compressed.      The    unobstructedness    of    the    operative 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  75 

area  permits  of  operating  accurately  and  neatly.  If  blood  flows  into 
the  pharynx,  the  patient  is  always  able  to  prevent  its  aspiration,  all 
reflexes  being  maintained.  The  patients'  condition  after  the  operation 
is  most  favorable;  they  leave  the  operating  table  perfectly  well  and 
rarely  have  to  be  put  to  bed.  Owing  to  the  effect  of  scopolamin,  they 
frequently  have  little  or  no  reminiscence  of  the  operation.  It  is  not 
saying  too  much  that,  owing  to  the  employment  of  local  anesthesia 
and  suprarenin  anemia,  resection  of  the  maxilla  has  lost  all  its  terrors. 
Local  anesthesia  in  this  operation  is  not  only  equivalent  to  general  anes- 
thesia but  far  superior." 

Major  operations  on  the  tongue  also  can  be  performed  under  local 
anesthesia.  Braun  undertook  even  more  complicated  operations, 
performing  extensive  extirpations  of  glands,  temporary  separation  of 
the  maxilla,  and  removal  of  maxillary  bone  fragments  under  local 
anesthesia.  The  anemia  produced  by  the  suprarenin  greatly  facilitates 
the  technical  execution  of  such  operations.  He  also  mentions  3  cases 
of  carcinoma  of  the  tongue  and  the  floor  of  the  oral  cavity  which  were 
operated  upon  under  local  anesthesia. 

Advantages  of  Local  Anesthesia  in  Surgery. — "Local  anesthesia 
has  been  charged  with  being  too  complicated,  therefore  unsuitable 
for  extensive  clinical  practice.  This,  however,  is  unjust.  Schleich's 
infiltration  anesthesia,  to  be  sure,  was  complicated,  since  the  scalpel 
had  to  aid  the  syringe  continually,  and  even  then  no  satisfactory 
anesthesia  could  be  obtained.  The  patients  became  restless,  began 
to  complain,  and  often  general  anesthesia  had  to  be  resorted  to  in  the 
end.  The  operations  were  thereby  unduly  prolonged,  and  the  patients 
as  well  as  the  operator  were  greatly  disappointed.  Not  so  with  the 
modern  method  of  local  anesthesia.  All  injections  are  made  before 
the  operation,  if  desirable  even  before  sterilization  of  the  field  of 
operation.  The  injections  require  no  longer,  usually  a  much  shorter 
time,  than  the  production  of  general  anesthesia.  If  several  operations 
have  to  be  made  in  succession,  the  assistant  can  make  the  injections 
in  a  separate  room  shortly  before  termination  of  the  preceding  opera- 
tion, so  that  no  time  whatever  is  lost.  If  the  correct  technique  is 
employed,  there  is  no  need  for  long  waiting.     After  completion  of  the 


76  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

injection,  we  immediately  prepare  ourselves  for  the  operation,  and 
this  preparation  requires  but  a  short  time  if  aseptic  gloves  and  long- 
sleeved  aseptic  operating-coats  are  worn.  In  the  meantime  the  field 
of  operation  is  sterilized.  If  the  operation  is  begun  within  from  eight 
to  ten  minutes  following  the  injection,  complete  anesthesia  will  have 
been  established.  In  large  surgical  institutions  the  saving  in  assistants 
and  anesthetists  afforded  by  the  routine  practice  of  local  anesthesia 
is  a  considerable  one. 

"Since  the  patients  retain  consciousness,  and  a  continual  con- 
versation can  be  carried  on  between  operator  and  patient,  disturbing 
movements  of  defense,  if  the  anesthesia  is  temporarily  superficial, 
can  be  prevented,  and  the  patient  is  able  to  cooperate  in  making  minor 
changes  in  position,  etc.,  without  the  assistance  of  a  third  person." 
(Peuckert.) 

This  most  favorable  report  speaks  so  eloquently  for  the  employ- 
ment of  local  anesthesia  in  major  surgery  that  it  is  surprising  that 
dentistry,  being  a  specialty  of  minor  surgery,  has  not  yet  definitely 
and  unconditionally  adopted  this  practice.  As  Braun  expresses  it  in  a 
personal  letter:  "In  surgery  cocain  has  become  obsolete  since  the 
introduction  of  novocain,  and  is  no  longer  used.  The  old  drugs  such  as 
cocain  are,  of  course,  still  being  sold  by  supply  houses  as  long  as  there 
is  a  demand  for  them."  This  proves  beyond  all  further  argument 
how  fully  justified  is  our  demand  that  novocain  be  substituted  for 
cocain. 

The  investigations  of  Braun  also  show  that  a  considerable  reduc- 
tion in  the  concentration  of  the  novocain  solution  is  indicated  in  local 
anesthesia.  In  the  normal  solutions  Nos.  i,  2,  and  3,  as  above  recom- 
mended, this  desideratum  has  been  taken  into  account.  Just  as  the 
I  per  cent,  novocain  solution  employed  by  Braun  has  yielded  remark- 
ably good  results,  so  solutions  ranging  from  0.5  to  1.5  per  cent,  when 
adapted  to  individual  cases  in  dental  practice,  guarantee  full  success, 
depending,  of  course,  to  a  great  extent  upon  the  technique  of  injection 
and  the  precautionary  measures  employed. 

In  a  recent  work  which  appeared  in   1912,^   Braun  published  an 

1  Ergebnisse  der  Chirurgie  u.  Orthopadie,   1912,  vol.  iv. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  77 

additional  report  of  clinical  experiences  with  local  anesthesia,  which 
is  no  less  favorable.  Also  in  the  recently  published  third  edition  of 
his  Text-book  on  Local  Anesthesia  he  reiterates  his  unconditional 
adherence  to  the  principles  of  local  anesthesia  as  formerly  pronounced 
by  him. 

While  local  anesthesia  originally  was  specially  indicated  in  minor 
surgery  and  in  emergency  cases  only,  it  is  gradually  gaining  a  firm 
foothold  in  major  surgery,  as  appears  from  the  following  reports  of 
various  hospitals: 


Heidelberg  Surgical  Clinic  (Dr.  Narrath)    . 

Stettin  Municipal  Hospital  (Dr.  Hesse) 
Zwickau  Charity  Hospital  (Dr.  Braun) 

Berlin  Charite  (Dr.  Axhausen) 1910  1600  ....  240 

Owing  to  the  absence  of  irritation  and  toxicity,  novocain  has 
superseded  cocain  almost  everywhere;  for  instance,  in  Germany, 
England  and  her  colonies,  South  America,  and  Russia.  In  France,  also, 
novocain  has  been  introduced  in  place  of  cocain  by  Reclus  in  191 1. 
To  cite  Piquand:  "Novocain,  at  the  present  time,  appears  to  be  the 
most  efficient  local  anesthetic.  Its  extremely  low  toxicity  permits  of 
injecting  large  doses  without  danger,  and  of  performing  complicated 
operations  which  would  be  extremely  difficult  under  cocain.  The 
only  possible  objection  to  novocain,  i.  e.,  the  short  duration  of  the 
resulting  anesthesia,  is  eliminated  by  the  addition  of  minimal  quantities 
of  adrenalin,  which  produces  a  remarkable  prolongation  and  intensi- 
fication of  the  anesthesia  without  materially  increasing  the  toxicity 
of  the  anesthetic." 


Year. 

No.  of 
opera- 
tions. 

General 

anes- 
thesias. 

Local 
anes- 
thesias. 

1906 
1907 
1908 
1910 

1917 
1936 
2070 
2303 

1633 
1377 
1460 

1583 

218 
426 

559 

632 

1908 
1909 

1762 
1940 

1364 
1294 

199 

413 

1908 
1909 
1910 

1529 

1542 
1811 

1078 

995 
1029 

375 
489 

727 

78         MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

Braun's  experiments  regarding  the  addition  of  sodium  bicarbonate 
to  the  solution  for  the  purpose  of  reducing  the  concentration  of  the 
novocain  have  shown  that  "this  solution  possesses  no  essential  advan- 
tage over  the  ordinary  normal  salt  solution  with  novocain." 

It  is  almost  impossible  to  fix  the  maximal  dose  of  novocain  because, 
as  Braun  remarks,  the  toxicity  of  this  agent  depends  as  much  upon 
the  concentration  and  the  manner  of  employment  of  the  solution  as 
upon  the  dosage.  For  surgical  purposes,  from  0.5  to  2  per  cent,  solu- 
tions are  usually  employed  in  combination  with  suprarenin.  Nast  and 
Kolb  have  injected  up  to  50  c.c.  of  a  i  per  cent,  solution,  Axhausen  up 
to  170  c.c,  and  in  one  case  as  much  as  200  c.c,  i.  e.,  2  grams  of  the 
drug.  Of  the  1.5  per  cent,  solution  Borchardt  has  administered  up 
to  150  c.c,  Hesse  up  to  220  c.c,  Braun  from  100  to  200  c.c,  in  some 
cases  even  250  c.c,  i.  e.,  1.5  grams  of  the  drug.  Excepting  occasional 
vomiting  immediately  following  injection,  surgeons  have  not  noted 
any  untoward  sequelae  from  these  doses,  hence  Braun's  statement 
that  "of  these  0.5  to  i  per  cent,  solutions  it  is  permissible  to  inject  so 
large  quantities  as  are  necessary  in  a  given  case  for  the  local  anes- 
thetization of  the  field  of  operation." 

If  more  highly  concentrated  solutions  are  used  of  course  the 
injected  quantity  must  be  considerably  reduced;  the  dose  of  20  c.c.  of 
a  2  per  cent,  solution  must  not  be  exceeded.  For  superficial  anesthesia 
of  mucous  membranes,  etc.,  by  topical  application,  novocain  is  not  so 
efficacious  as  alypin,  which  is  being  used  most  successfully  in  10  per 
cent,  solutions  with  suprarenin,  in  otology,  rhinology,  and  laryngology. 

As  has  been  said  before,  Braun  originally  advocated  four  solutions, 
i.  e.,  0.25,  0.5,  I  and  2  per  cent.,  with  carefully  graduated  additions 
of  suprarenin.  At  present,  0.5  per  cent,  solutions  or,  if  extensive 
conductive  anesthesia  is  desired,  from  i  to  2  per  cent,  solutions  are 
chiefly  employed.  Braun  prepares  all  his  solutions  from  novocain- 
suprarenin  tablets  A,  which  contain  0.125  grams  of  novocain  and 
0.000096  gram  of  synthetic  suprarenin.  The  required  number  of 
tablets  is  transferred  into  a  sterile  test-tube,  covered  with  a  small 
quantity  of  normal  salt  solution,  dissolved  by  vigorous  boiling  over  an 
alcohol  flame,  and  diluted  in  a  porcelain  graduate  with  sterile  normal 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  79 

salt  solution;  lOO  c.c.  of  a  i  per  cent,  solution,  or  50  c.c.  of  a  2  per 
cent,  solution,  prepared  in  this  manner,  contain  about  i  mg.  of 
suprarenin.  The  method  of  preparing  a  solution  from  tablets 
Braun   considers   the    simplest   and    most   reliable. 

The  opinion  that  the  healing  process  following  dental  operations 
may  be  disturbed  by  local  anesthesia  is  regarded  as  erroneous  by 
Braun,  because  no  disturbances  in  the  healing  process  are  noted. 

"Local  anesthesia  in  its  present  form  is  harmless.  It  was  not 
perfect  in  the  beginning,  of  course,  and  for  the  tyro  in  the  technique 
it  is  even  yet  not  entirely  without  risks.  The  introduction  of  novo- 
cain-suprarenin  has  greatly  broadened  the  scope  of  local  anesthesia, 
because  large  quantities  of  a  most  efficacious  anesthetic  solution  can 
be  introduced  into  the  body  with  impunity.  Among  other  operations, 
we  employ  local  anesthesia  for  all  strumectomies,  all  hernia  opera- 
tions except  in  children,  the  majority  of  operations  in  the  male  sexual 
organs,  and  in  the  rectum,  also  for  resections  of  the  maxillae  and  opera- 
tions on  the  tongue.  In  all  these  the  use  of  cocain  would  be  impossible. 
We  inject  150  c.c.  and  over  of  a  0.5  per  cent,  novocain  solution  with 
an  infinitesimal  amount  of  suprarenin,  as  contained  in  the  A  tablets. 
I  have  never  observed  any  intoxication  or  other  untoward  secondary 
effects  from  novocain,  except  occasional  vomiting  following  very 
large  doses.  He  who  returns  to  cocain  makes  a  step  backward  and 
betrays  his  lack  of  technical  skill.  Such  perfect  and  safe  anesthesia 
as  can  be  produced  by  novocain-suprarenin  cannot  be  obtained  with 
cocain.  Nobody,  of  course,  will  dispute  that  cocain  per  se  is  a  stronger 
anesthetic  than  any  of  its  substitutes  or  than  novocain;  but  novocain 
allows  of  an  infinitely  wider  range  of  application  without  risk. 

''Local  anesthesia  is  harmless,  provided  no  cocain  is  used,  and  the 
suprarenal  preparation  employed  is  pure  and  free  from  decomposition. 
This  is  the  reason  why  I  am  advocating  the  tablet  form  so  strongly. 
In  dentistry  such  high  doses  as  might  eventually  produce  untoward 
sequelae  are  not  even  approached.  The  maxilla,  the  mandible,  and 
all  the  organs  of  the  oral  cavity  can  be  anesthetized  at  one  time  with 
such  small  quantities  of  the  solution  that  untoward  sequelae  cannot 
be  reasonably  expected. 


80  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

"The  practice  of  leaving  it  to  the  patient  whether  general  or  local 
anesthesia  should  be  resorted  to,  is  most  reprehensible.  Patients 
have  no  idea  of  the  requirements  of  their  case;  all  they  wish  is  that  the 
operation  be  painless.  It  is  for  the  operator,  and  for  him  only,  to 
decide  just  what  is  to  be  done,  and  how  it  is  to  be  done.  It  goes  with- 
out saying  that,  if  the  patient's  mental  condition  demands  it,  general 
anesthesia  must  be  resorted  to,  even  though  local  anesthesia  would 
be  feasible.  This  applies  especially  to  many  children  and  those  adults 
who  act  like  children.  Even  then,  the  decision  should  not  be  governed 
by  the  patient's  wishes  but  by  the  operator's  judgment." 

From  the  foregoing  considerations  there  is  no  denying  the  fact 
that  local  anesthesia,  especially  by  novocain-suprarenin  solution,  is 
bound  to  occupy  a  leading  position  in  modern  dental  practice.  The 
claim  that,  in  regard  to  the  anemia  produced,  novocain-suprarenin 
is  inferior  to  cocain-suprarenin,  must  be  energetically  refuted,  for, 
according  to  Braun,  ''the  anesthetic  action  of  novocain  is  at  least 
fully  equal  in  intensity,  duration,  and  extension  to  that  of  cocain. 
Novocain  is  an  ideal  anesthetic,  which  not  only  is  destined  to  super- 
sede cocain  entirely,  but  which  has  greatly  enhanced  the  safety  of 
local  anesthesia  owing  to  the  possibility  of  injecting  with  impunity 
much  greater  quantities  of  efficacious  anesthetic  solutions." 


THE    INSTRUMENTARIUM. 

The  instrumentarium  selected  for  injection  anesthesia  fully  complies 
with  all  modern  rules  of  asepsis  and  can  be  subjected  to  any  form 
of  sterilization,  especially  boiling. 

The  Injection  Syringe. — The  selection  of  a  suitable  syringe,  this 
most  important  instrument,  has  always  involved  the  greatest  diffi- 
culties, because  syringes  with  leather  piston,  which  are  the  tightest, 
cannot  be  exposed  to  steam,  while  most  glass-and-metal,  all-glass,  or 
all-metal  syringes,  do  not  have  a  hermetically  fitting  piston.  After 
examining  a  great  number  of  models  we  have  designed,  with  the  assist- 
ance of  Freienstein,  of  Berlin,  a  syringe  which  promises  to  fulfil  all  the 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  81 


Fig.  3a 


Fig.  %b 


injection  syringe  of  glass  and  metal, 
designed  by  Dr.  Guido  Fischer.  (For 
explanation  of  lettering  sec  Fig.  4.) 

6 


Syringe  with  hub  for  telescoping  trocar 
needle. 


82 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


necessary  requirements.  In  view  of  the  thorough  tests  of  the  past 
few  years  this  syringe  has  indeed  surpassed  all  expectations,  and  has 
proved  superior  to  all  other  partly  antiquated  models  which  are 
advertised  for  dental  purposes. 


Needle  in  short  hub.  Needle  in  long  hub. 


Needle  screwed  uti  syringe 
{cross-sectiun). 


Closing  cap. 


M 


1 

Improved  needle. 


^2 


hub. 


Wrench. 


Needles,  hubs,  and  wrench  for  injection  syringe,  designed  by  Dr.  G.  Fischer. 
On  the  right  is  a  considerably  enlarged  reproduction  of  the  new  needle  showing  the  details  of  con- 
struction as  follows:  i,  the  hollow  needle,  either  of  seamless  steel,  pure  nickel,  gold  or  iridio-plati- 
num;  2,  body  of  soft  metal  for  firmly  tightening  the  needle  upon  the  orifice  of  the  syringe;  3,  conical 
shell  of  hard  metal,  open  below,  from  which  the  soft  metal  core  protrudes.  This  arrangement 
remedies  the  deficiencies  of  the  old-style  needles  in  which  the  unprotected  soft  metal  cone  could 
not  stand  much  use,  became  flattened  easily,  and  jammed  in  the  hub  so  firmly  that  both  hub  and 
needle  had  to  be  replaced,  which  was  rather  expensive  when  gold  or  iridio-platinum  needles  were 
used.  The  new  needles  are  attached  to  the  syringe  absolutely  tightly  by  inserting  the  needle  in  one 
of  the  hubs  {B  or  C)  and  screwing  it  firmly  on  the  orifice  of  the  syringe.  In  order  to  enable  prac- 
titioners with  sensitive  fingers  to  manipulate  the  hubs  easily,  which  heretofore  were  milled,  the 
hubs  B  and  C  are  made  with  hexagonal  connections,  so  that  they  can  be  conveniently  and  firmly 
tightened  by  a  slight  turn  of  the  wrench.  No  force  should  be  used,  otherwise  the  soft  metal  cone 
of  the  needle  becomes  unnecessarily  worn. 


This  syringe  is  made  of  glass  and  metal,  resembling  in  principle 
the  Progress  syringe,  and  is  constructed  so  as  to  avoid  all  minute  fur- 
rows and  corners  which  catch  dirt  and  are  difficult  to  clean  (see  Fig.  3). 
The  entire  outer  surface  of  the  syringe  is  uniformly  round  and  smooth, 
and  the  hubs  B  and  C  are  tightened  with  a  wrench  (see  Fig.  4).  The 
metal  piston  is  made  accurately  so  as  to  fit  tightly  in  the  glass  barrel, 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN 


83 


and  terminates  in  a  crutch-shaped  handle,  so  that  it  can  be  con- 
veniently laid  against  the  ball  of  the  thumb  and  firmly  braced  there. 
This  handle,  being  threaded  and  fastened  in  a  screw  socket,  can  be 
shortened  or  lengthened  at  convenience.  To  allow  for  the  exertion 
of  such  pressure  as  is  necessary  for  injection,  two  wing-like,  strong, 
and  milled  finger  rests  are  fitted  to  the  metal  sheath  of  the  syringe 
barrel;  these  finger  rests  are  a  little  smaller  in  the  i  c.c.  syringe  than 
in  the  larger  size. 

Fig.  5 


A  A  A 

1  17  18 

a      b       c 
Improved  injection  needles  for  dental  practice:    No.  i,  length,  42  mm.  with  long  point;  diameter, 
0.9  mm.;  No.  17,  a,  length,  23  mm.;  b,  length,  26  mm.;  c,  length,  42  mm.;  diameter,  0.47  mm.;  No. 
18,  length,  16  mm.;  diameter,  0.42  mm. 

For  practical  reasons  this  syringe  is  made  in  two  sizes,  one  holding 
I  c.c,  the  other  2  c.c.  of  solution.  On  the  glass  barrel  a  scale  is  etched 
for  gauging  the  contents.  After  some  time,  viz.,  after  from  three  to 
six  months  of  continual  use,  the  piston  wears  and  should  then  be 
replaced,  as  it  loses  its  required  tightness.  It  is  best  always  to  keep 
three  or  four  syringes  of  both  sizes  on  hand — a  luxury  which  will  pay 
in  the  end. 

Hubs. — The  syringe  is  sold  with  various  smooth  hubs  (see  Figs.  3 
and  4,  B  and  C),  which  are  selected  according  to  the  place  of  injec- 
tion.    The  closing  cap  A  is  used  to  close  up  the  barrel  after  use. 

Steel  Needles.  —  For  our  purposes  the  needles  No.  17,  with  short 
points  (see  Fig.  5),  are  employed.  The  needles  Nos.  i  and  18  (see  Fig. 
5)  are  designed  for  special  purposes,  as  follows:    No.  i   (diameter  0.9 


84  MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

mm.)  which  is  preferred  by  Williger,  for  mandibular  anesthesia;  No.  i8, 
for  subperiosteal  injection,  if  a  specially  short  needle  is  desired.  The 
trocar  needles  (see  Figs.  6  and  7)  have  proved  very  serviceable  in  con- 
ductive anesthesia  in  the  upper  jaw. 

The  three  needles  No.  17  have  a  diameter  of  0.47  mm.,  a  being 
23  mm.,  h  26  mm.,  and  c  42  mm.  long.  In  contradistinction  to  needle 
No.  I,  the  needles  Nos.  17  and  18  are  ground  with  blunt  ends  (Fig.  5), 
which  are  indispensable  if  the  needle  is  to  come  into  direct  contact 
with  the  bone.  Long  and  tapering  needle-points  are  not  suitable, 
because  they  easily  get  stuck  in  the  periosteum  and  bone,  break  or 
bend,  and  cause  complications.  In  mandibular  anesthesia,  however, 
where  the  needle  is  advanced  along  the  bone,  we  prefer  needle  No.  17 
to  No.  I,  since  the  orifice  of  the  No.  i  needle  may  allow  of  a  too  rapid 
and  liberal  discharge  of  the  fluid. 

The  needles  have  been  so  improved  by  Freienstein  that  they  can  be 
firmly  locked  in  the  hubs,  and  hermetical  closure  during  the  injection 
is  guaranteed  (see  Fig.  4,  No.  2).  The  cone  of  soft  metal  is  protected 
by  a  hard  metal  case  of  heavily  gilded  copper;  it  is  open  below,  so 
that,  even  under  firm  pressure,  flattening  of  the  soft  metal  cone  and 
sticking  of  the  needle  in  the  hub  are  prevented.  This  arrangement 
also  insures  the  exactly  central  position  of  the  needle  and  prevents  all 
possibility  of  leakage  (see  Fig.  4). 

Whenever  possible  a  new  steel  needle  should  be  used,  since  needles 
which  have  not  been  perfectly  dried  after  use  rust  and  break.  By 
repeated  use  the  needle  becomes  dull  and  unfit.  It  is  a  good  plan  to 
employ  one  needle  for  one  day's  work,  and  discard  it.  After  finishing 
a  case,  the  needle  is  drawn  several  times  through  absolute  alcohol 
and  removed,  and  its  lumen  vigorously  blown  out  with  a  hot  air 
syringe;  a  small  wire  is  then  introduced,  and  the  needle  laid  in  a  dry 
test-tube  ready  for  the  next  injection.  For  the  next  case,  it  is  screwed 
to  the  filled  barrel  and  immersed  in  boiling  water  for  a  minute. 

Iridio-platinum  Needles. — The  use  of  iridio-platinum  needles  can- 
not be  too  strongly  advocated,  because  they  can  be  sterilized  in  a 
flame  before  and  after  use,  and  do  not  break  so  easily.  They  possess 
sufficient  elasticity  to  allow  the  operator  to  remain  in  constant  contact 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  85 

with  the  bone,  as,  for  instance,  in  advancing  to  the  inferior  dental  fora- 
men. If  excessive  pressure  is  exerted  or  unusual  resistance  is  met 
with  they  give  and  bend;  but  this  is  a  minor  disadvantage  as  com- 
pared with  breaking,  which  may  happen  with  steel  needles.  Once 
mounted,  an  iridio-platinum  needle,  so  long  as  it  is  perfect,  may  remain 
upon  the  syringe  for  months;  it  will  not  rust  or  wear  out  quickly  with 
use,  and  is  therefore  cheaper  and  more  reliable  than  steel  needles, 
which  must  be  new. 

The  Trocar  Needle. — For  conductive  anesthesia  in  the  upper  jaw, 
blunt  and  strong  trocar  needles  with  sliding  attachment  seem  prefer- 
able. These  allow  of  more  certain  manipulation  than  the  needles 
No.  17  as  formerly  used,  lessen  the  risk  of  breaking,  and,  being  blunt 
and  slightly  curved,  prevent  injuries  to  important  vessels  in  the  area 
of  injection,  especially  in  injection  at  the  maxillary  tuberosity,  as 
Gasser  has  demonstrated  in  anatomic  preparations.  These  trocar 
needles  have  been  very  successfully  employed  in  lumbar  anesthesia. 
For  our  purposes  the  needle  should  be  so  constructed  that,  when 
inserted,  its  point  sharply  separates  the  tissues,  but,  after  passing 
the  mucous  membrane  and  the  muscular  fibers,  advances  as  a  blunt 
point.  It  can  easily  be  pushed  forward  along  the  bone  without  per- 
forating or  lacerating  any  vessels  or  nerves.  Excellent  results  have 
been  obtained  with  a  slightly  curved  trocar  needle  (see  Figs.  6  and  7) 
of  7  cm.  length  and  i  mm.  diameter,  and  a  hub  which  can  be  slid  upon 
a  suitable  middle  piece  screwed  to  the  syringe  (see  Fig.  3&).  The 
curvature  of  the  needle  corresponds  to  the  protuberance  at  the  maxil- 
lary tuberosity  and  insures  continual  contact  with  the  surface  of 
the  bone  in  advancing  the  needle.  The  needle  canal  contains  a  trocar 
of  fitting  size  which  protrudes  from  i  to  1.5  mm.  beyond  the  needle- 
point and  affords  a  sharp  point  for  insertion.  The  sterile  trocar 
needle  is  gently  pushed  through  the  mucous  membrane  and  muscle 
fibers  to  the  surface  of  the  bone,  the  inner  sharp  trocar  is  withdrawn, 
the  full  syringe  is  slid  upon  the  needle-hub  (see  Fig.  3^),  and  the  needle 
gradually  advanced  along  the  bone  while  discharging  the  anesthetic 
solution.  If  necessary,  the  syringe  can  be  removed,  refilled,  and 
reattached  to  the  needle  which  remains  in  situ. 


86        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

In  conductive  anesthesia  at  the  maxillary  tuberosity  this  needle 
has  proved  most  satisfactory.  In  conductive  mandibular  anesthesia 
also  the  same  principle  can  be  applied  and  offers  the  following  great 
advantages:     unobstructed  view  in   inserting   the  needle,   continuous 

Fig.  6 


Trocar  needles  with  telescoping  attachments. 

contact  with  the  bone,  no  tissue  lesions,  and  no  danger  of  breaking 
the  needle.  In  mandibular  work  a  straight  needle  is  superior  to  a 
curved  one,  preference  to  be  given  to  a  thicker  model  of  i  mm. 
diameter. 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  87 

In  the  technical  execution  of  conductive  anesthesia  this  form  of 
needle  appears  to  be  preferable  to  the  sharp  and  thin  needle.  The 
danger  of  breaking  a  needle  is  practically  eliminated,  the  certainty 
in  guiding  it  is  enhanced,  and  vascular  lesions  are  prevented.    Hemato- 

FiG.  7 


Trocar  needles. 


mata,  such  as  sharp  needles  may  produce,  can  hardly  occur,  especially 
at  the  maxillary  tuberosity.  For  the  insertion  itself,  a  sharp  point 
is  necessary  because  in  both  jaws  taut  mucous  membrane  and  dehcate 
muscle  fibers  must  first  be  penetrated,  after  which  the  needle  advances 


88        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

through  very  loose  interstitial  connective  tissue  where  the  solution  is 
deposited.  With  either  form  of  needles  no  untoward  sequelae  such  as 
infection,  hemorrhage,  etc.,  at  the  point  of  insertion  have  been  noted; 
neither  need  infiltration  of  the  muscles  be  feared,  because  the  injec- 
tion is  always  made  into  loose  connective  tissue  after  the  muscle  fibers 

have  been  penetrated. 

Fig.  8 


Glass  jar  with  metal  stand  for  preserving  syringes  in  a  sterile  alcohol-glycerin  solution. 

Treatment  of  the  Syringe. — The  syringe  is  best  kept  in  a  tall  vessel 
with  stand  (see  Figs.  8  and  lo),  containing  two  parts  absolute  alcohol 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  89 

and  one  part  of  chemically  pure  glycerin.  This  solution  remains 
sterile  and  does  not  attack  the  metal  parts.  Before  and  after  use,  hot 
distilled  water  is  drawn  into  the  syringe  several  times,  the  iridio- 
platinum  needle  is  sterilized  in  a  flame,  and  the  syringe  and  needle 
are  returned  to  the  glass  jar  (see  Figs.  8  and  lo).  It  is  best  to  have  the 
syringe  dip  into  the  alcohol-glycerin  mixture  down  to  the  hub.  For 
washing  off  the  alcohol  and  glycerin,  distilled  water  alone  should 
be  used,  since  alkaline  water  precipitates  novocain  and  renders  the 
solution  ineffectual. 

In  this  connection  Riethmiiller^  writes:  "The  syringes,  with 
hub  and  needle  attached,  are  best  kept  suspended  in  an  upright 
glass  jar  filled  with  absolute  alcohol  and  fitted  with  a  German  silver 
stand  to  prevent  dulling  of  the  needle  point  by  resting  on  the  bottom 
of  the  vessel.  Such  a  stand  can  be  shaped  up  and  soldered  quickly 
by  any  mechanic.  The  jar  is  covered  with  a  flat  glass  cover  with 
ground  edge,  which  is  vaselined,  and  this  cover  is  kept  tightly  on  the 
jar  overnight  by  binding  it  down  with  strips  of  adhesive  plaster  to 
prevent  evaporation  of  the  alcohol.  The  flat  cover  is  preferable 
to  a  ground  glass  stopper,  which  sometimes  is  very  difficult  to 
remove.  Alcohol  of  70  per  cent,  has  been  found  more  strongly 
bactericidal  than  absolute  alcohol;  still,  absolute  alcohol  may  be 
preferably  used  as  it  soon  absorbs  enough  water  from  the  atmos- 
phere to  approximate  it  to  that  alleged  optimum  percentage.  In 
the  Bardet  syringe  sterilizer,  which  is  used  by  some  operators,  only 
the  needle  is  kept  sterile  by  immersion  in  lysol,  while  the  greater 
portion  of  the  barrel  and  piston  are  exposed  to  undesirable  contamina- 
tion with  microorganisms  from  the  air. 

"On  removing  the  syringe  from  its  alcohol  bath,  some  of  the  alcohol 
is  drawn  through  the  needle  and  barrel,  pressed  out  and  burnt  off  by 
passing  through  a  flame. 

"After  the  alcohol  is  burnt  off,  hot  water  is  drawn  into  the  syringe, 
as  any  trace  of  alcohol  which  is  not  thus  removed  would  produce 
anesthesia  lasting  several  days,  as  is  appreciated  by  anyone  familiar 
with  the  treatment  of  trifacial  neuralgia  by  alcohol  injections.     The 

'  Denial  Cosmos,  February,  1913. 


90 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


hot  water  also  heats  the  syringe,  and  prevents  the  anesthetic  solution 
from  cooling  below  blood  temperature." 

If  glycerin  is  mixed  with  the  alcohol,  which  will  keep  the  instru- 
ment bright  and  slightly  lubricated,  a  thorough  washing  in  hot  dis- 
tilled water  is  the  only  feasible  procedure. 

Ampoules. — If  ampoules  are  employed,  one  proceeds  as  follows: 
The  ampoule  is  sterilized,  the  neck  broken  in  a  sterile  linen  napkin, 
and  the  contents  drawn  into  the  syringe  through  the  mounted  needle. 
It  is  advisable  first  to  immerse  the  ampoule  in  hot  water  in  order  to 
raise  the  solution  to  body  temperature. 

Fig.  9 


Stasis  bandage  applied  to  patient's  neck.     Diminishes  danger  of  intoxication  and  anemia  of   the 

brain,  and  retards  absorption. 

Stasis  Bandage. — Finally,  a  very  practical  addition  to  the  instru- 
mentarium  should  be  mentioned,  i.  e.,  the  stasis  band,  as  devised 
by  the  writer  for  certain  complicated  cases.  This  is  adjusted  by 
means  of  a  number  of  eyelets,  and  fitted  around  the  patient's  neck 
tightly  enough  to  cause  the  face  to  become  slightly  reddened  (see  Fig. 
9) ;  deep  red  or  blue  coloration  must  be  avoided.  This  bandage  pro- 
duces compression  of  the  jugular  veins  and  retards  the  return  of 
the  venous  blood  from  the  head,  thereby   rendering   cerebral  anemia 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN  91 

unlikely,  and  retarding  the  absorption  of  the  anesthetic  solution. 
In  this  way  still  greater  certainty  of  success  is  guaranteed,  the  danger 
of  intoxication  is  minimized,  and  fainting  spells  due  to  cerebral  anemia 
are  prevented,  or  at  least  the  likelihood  of  their  occurrence  is  lessened. 
The  hyperemia  which  follows  this  stasis  seems  advantageous  for  the 
healing  process,  and  is  never  pronounced  enough  to  produce  hemor- 
rhage, but  ranges  within  moderate  physiological  limits.  For  the 
formation  of  clot  in  wounds,  the  hyperemia  following  removal  of  the 
bandage  is  of  incalculable  value,  preventing,  as  it  does,  disturbances 
in  the  healing  process,  postoperative  pain,  necrosis,  etc.,  which  may 
follow  excessive  anemia.  Normal  circulation  is  rapidly  reestablished 
after  removal  of  the  stasis  bandage,  which  in  special  cases  has  proved 
very  successful. 

Seidel,  like  other  writers  who  seem  to  have  misunderstood  the 
purpose  of  this  bandage  and  apparently  have  never  given  it  a  fair 
trial,  has  raised  the  objection  that  its  "cumbersome,  conspicuous, 
and  disagreeable  application  preceding  an  extraction  materially 
increases  the  patient's  fear  as  well  as  the  danger  of  fainting,  and  com- 
plicates the  operator's  work."  In  reply  to  these  objections  it  must 
be  emphasized  that  in  delicate  and  anemic  persons  the  bandage  renders 
invaluable  service,  as  any  one  will  admit  who  has  taken  the  pains 
to  test  it — not  in  two  or  three  but  in  hundreds  of  cases.  Many  dental 
and  general  surgeons  have  reported  most  favorable  results  from  the 
application  of  this  bandage,  which  fully  deserves  a  place  in  our 
instrumentarium. 

It  goes  without  saying  that  it  is  not  to  be  applied  in  every  case, 
nor  was  it  ever  intended  for  routine  practice.  It  is  indicated,  however, 
in  delicate  patients  of  livid  complexion  who  are  subject  to  fainting.  The 
operator's  judgment  will  determine  the  cases  in  which  this  valuable 
accessory  may  be  resorted  to  with  advantage. 

A  Modified  Instrumentarium. — After  experimenting  with  various 
modifications  of  the  Fischer  instrumentarium,  Riethmtiller  has  devised 
a  set  of  three  pieces  which  have  proved  most  practical  by  their  sim- 
plicity and  compactness.  First,  instead  of  a  glass  jar  with  ground 
cover,  which  easily  sticks,  an  anatomic  specimen  jar  is  used,  allowing 


92 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


the  flat  cover  with  rubber  washer  to  be  clamped  down  tightly.  This 
handy  jar  contains  a  suitable  metal  stand  providing  for  two  Fischer 
syringes,  a  pair  of  pliers  of  aluminum,  which  metal  is  not  corroded 
by  the  iodin  used  for  disinfection  of  the  mucous  membrane,  and  for 


Fig.  loa 


Fig.  lob 


Hermetically  sealed  glass  jar  for  preserving 
syringes,  dissolving  cup,  and  pliers  in  alcohol- 
glycerin  solution. 


Diagram  showing  arrangement  of  metal 
stand  in  glass  jar. 


suspending  the  dissolving  cup  in  the  alcohol-glycerin  solution  (see  Fig. 
lo).  Second,  for  preserving  the  modified  Ringer  solution  a  stock  flask 
is  used,  which  is  hermetically  closed  with  a  ground  stop-cock,  doing 
away  with  the  danger  of  bacteria  accumulating  in  the  cotton  wad 
as   employed    in    the    Fischer  bottle  (see  Fig.   ii).     For  pouring  out 


THE  INJECTING  SOLUTION  OF  NOVOCAIN-SUPRARENIN 


93 


the  solution,  the  stop-cock  is  opened,  the  ground  cover  shghtly  turned 
in  the  neck  of  the  bottle,  so  that  a  minimum  of  air  is  admitted 
through  the  concentric  pinholes,  and  the  bottle  inclined.  For  filtering 
the  admitted  air,  a  piece  of  sterile  gauze  or  cotton  is  fastened  over 
the   airholes  with   a  rubber  band,   to   be  renewed   daily.     After   the 


Fig.  II 


Ivlodified  stock  flask  for  Ringer  solution. 


desired  amount  of  Ringer  solution  has  been  poured  out,  the  stop-cock 
is  closed,  and  the  ground-glass  stopper  turned,  so  that  all  air  is 
excluded  until  the  next  use.  Third,  for  protecting  the  syringe  from 
contamination  or  the  needle-point  from  becoming  dulled  accidentally, 
a  glass  tray  is  fitted  with  a  metal  inset  which  accommodates  two 
filled  syringes  mounted  with  short  or  long  needles.      This  tray  also 


94 


MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 


holds   a  small  glass   tray   with    ground    cover,   in  which  needles  and 
wrench  may  be  kept  in  an  antiseptic  solution  (see  Fig.  12). 


Fig.   12 


Glass  tray  with  metal  inset,  accommodating  two  filled  syringes  with  long  or  short  needles;  also  smaller 
covered  tray  for  preserving  wrench,  needles,  pulp  broaches,  etc.,  in  antiseptic  solution. 

In  designing  this  set  it  has  been  the  aim  to  perfect  the  individual 
links  in  the  chain  of  asepsis  to  the  highest  degree  feasible. 


DISINFECTION    OF    THE    FIELD    OF    OPERATION. 

Asepsis  in  Injecting. — As  the  injection  generally  precedes  surgical 
intervention  of  some  sort,  it  plays  a  part  in  the  subsequent  healing 
of  the  wound.  For  this  reason,  even  if  a  very  minute  quantity  is 
injected,  full  attention  must  be  paid  to  asepsis,  as  untoward  sequelae 
may  arise  from  neglect  of  one  of  the  factors  involved.  Many  cases  of 
edema  following  injections  are  attributable  to  insufhcient  asepsis, 
such  as  neglect  in  sterilizing  the  hands,  the  instruments,  the  solution, 
or  the  field  of  operation. 

Disinfection  of  the  Mucosa. — It  is  imperative  to  sterilize  not  only 
the  instruments  and  the  operator's  hands  before  making  an  injection 


DISINFECTION  OF  THE  FIELD  OF  OPERATION  95 

but  the  oral  mucosa,  which  is  always  infected,  must  also  be  subjected 
to  a  most  thorough  and  careful  sterilization.  Among  disinfectants, 
iodin  occupies  a  predominant  place.  Disinfection  with  iodin  (iodo- 
benzin)  has  been  generally  adopted  in  modern  surgery,  where  hardly 
any  incision  in  the  epidermis  is  made  without  previous  swabbing  with 
iodin.  This  antiseptic  not  only  possesses  a  deeply  penetrating  power 
but  also  produces  dryness  of  the  swabbed  area,  which  is  of  special 
advantage  in  the  oral  cavity. 

Effect  of  Iodin. — Tincture  of  iodin  (tincture  of  iodin  and  tincture 
of  aconite,  equal  parts),  according  to  Konig,  fulfils  the  requirements 
"which  are  considered  in  all  modern  efforts  at  disinfection  as  most 
essential,  i.  e.,  hardening  the  skin,  tanning  it,  as  it  were,  and  fixing 
the  bacteria  for  some  time  in  such  a  way  that  they  cannot  get  into 
the  wound.  That  iodin,  besides  these  properties,  retards  bacterial 
growth  is  a  well-known  fact."  Iodin  clings  for  a  long  time  to  the 
tissue  to  which  it  has  been  applied,  thus  insuring  deep  penetration. 
In  a  dilution  of  i  to  6000,  iodin  still  impedes  bacterial  growth.  Lewy 
justly  emphasizes  that  the  tanning  of  the  mucosa  is  an  advantage 
"facilitating,  as  it  does,  the  introduction  of  the  needle  into  spongy 
gums."  The  purely  superficial  brown  coloration  of  the  place  of  injec- 
tion is  also  of  importance,  as  it  very  clearly  marks  the  prepared  portion 
of  the  skin  to  be  injected.  The  objections  that  have  been  raised 
against  iodin  as  a  disinfectant  of  the  mucous  membrane  cannot  be 
maintained  unless  an  idiosyncrasy  for  iodin  be  present.  The  author 
has  never  noticed  any  lesion  or  sloughing  in  the  area  of  injection  fol- 
lowing the  application  of  weak  iodin. 

The  combined  action  of  iodin  and  aconite  (equal  parts)  upon  the 
mucous  membrane  also  successfully  counteracts  the  slight  pain  which 
would  otherwise  be  caused  by  the  insertion  of  the  hypodermic  needle, 
so  that  after  the  first  injection,  the  patient's  fear  of  the  needle-prick 
is  overcome  and  his  confidence  and  cooperation  are  fully  insured. 

Application  of  Iodin. — The  painting  with  iodin  is  accomplished 
by  not  merely  applying  a  few  touches,  but  by  repeatedly  wiping  to 
and  fro,  in  order  to  combine  real  mechanical  cleansing  with  the  disin- 
fection,  and   to  effect  penetration.     The  filled   syringe  is  once  more 


96        MODERN  LOCAL  ANESTHETICS  AND  THEIR  APPLICATIONS 

dipped  in  boiling  water,  the  iridio-platinum  needle  drawn  through  an 
alcohol  flame,  and  the  injection  is  then  made. 

The  author  has  also  successfully  employed  lo  per  cent,  thymol  alco- 
hol for  disinfecting  the  point  of  insertion  of  the  needle.  The  lack  of 
the  characteristic  brown  discoloration  following  the  application  of  tinc- 
ture of  iodin,  however,  seems  to  be  a  drawback. 

In  order  to  enable  him  to  observe  the  gradual  advance  of  the 
anemia  of  the  gum  following  the  injection,  which  is  a  valuable  symp- 
tom in  mucous  anesthesia,  Riethmiiller  prefers  one  of  the  colorless 
iodin  solutions,  which  is  also  appreciated  by  the  patient.  A  5  to  lO 
per  cent,  alcoholic  solution  of  iothion  (di-iodohydroxypropane)  has 
given  most  satisfaction,  as  it  causes  no  irritation  of  the  mucous  mem- 
branes like  excessively  strong  iodin  solution,  and  seems  to  be  applicable 
even  in  iodin  idiosyncrasy. 

PREPARATION  OF  THE  PATIENT  FOR  LOCAL 
ANESTHESIA. 

In  dental  cases,  no  preparation  of  the  patient  for  the  injection  is 
necessary,  as  a  rule.  In  cases  of  great  excitement  and  fear,  camphor- 
ated validol,  7  drops  in  a  little  water,  to  be  taken  internally,  acts  as  a 
sedative;  in  extreme  cases,  morphin  with  hyoscin  is  administered  by 
the  mouth. 

"For  various  reasons,"  Braun  writes,  "a  combination  of  local  with 
general  anesthesia  may  be  necessary  as  an  auxiliary,  if,  somehow  or 
other,  the  local  anesthetization  of  the  field  of  operation  is  insuflicient. 
Such  cases,  of  course,  will  occur  the  more  seldom  the  greater  the 
operator's  skill  and  experience. 

"The  method  of  preparing  the  patient  for  lumbar  anesthesia  by 
narcotics  such  as  morphin,  scopolamin,  veronal,  etc.,  as  first  sug- 
gested by  Kronig,  has  proved  very  useful  in  local  anesthesia.  Most 
patients,  however,  do  not  require  such  preparation,  which  in  minor 
interventions  is  not  indicated." 

"To    insure    uniformly    successful    results,"    Riethmiiller^    writes, 

1  Dental  Cosmos,  February,  1913. 


PREPARATION  OF  THE  PATIENT  FOR  LOCAL  ANESTHESIA         97 

"even  in  timid,  nervous,  and  obstinate  patients  and  in  children,  one 
or  two  tablets  of  bromural  should  be  given  internally  from  twenty 
to  thirty  minutes  before  injection.  The  agreeable  sedative  and  hyp- 
notic effect  of  this  drug  is  greatly  appreciated  by  the  timid  in  everyday 
dental  operations,  even  though  these  may  involve  nothing  more  than 
nervous  strain.  Bromural  is  more  easily  tolerated  and  absolutely 
harmless  as  compared  with  quinin,  chloral  hydrate,  or  morphin- 
hyoscin.  The  twilight  slumber  which  frequently  follows  the  internal 
administration  of  bromural  greatly  enhances  the  ease  with  which  our 
injections  can  be  made." 

Williger  reports  most  favorable  results  from  bromural  0.3  (one 
tablet)  for  children,  and  0.6  (two  tablets)  for  adults,  to  be  taken 
with  water  forty-five  minutes  before  operation;  also  from  scopolamin 
hydrobromid  0.006,  morphin  0.15,  distilled  water  10,  from  three  to 
six  divisions  of  a  Pravaz  syringe,  to  be  injected  hypodermically  one 
hour  before  operation. 

Concerning  scopolamin,  Riethmiiller  writes:  "Scopolamin,  to  be 
administered  hypodermically  by  a  Pravaz  syringe,  has  a  place  in  our 
medicinal  equipment,  and  is  especially  serviceable  in  preparing  alco- 
holics for  local  anesthesia.  Very  stubborn  or  neurasthenic  patients,  or 
those  in  whom  deep  general  anesthesia  is  absolutely  contra-indicated, 
may  be  induced  to  submit  to  local  anesthesia  by  being  given  a  few 
inhalations  of  ethyl  bromid  or  nitrous  oxid  and  oxygen,  if  available, 
the  mask  being  held  at  a  distance  from  the  face  until  superficial 
slumber  has  set  in." 


PART  11. 

INDICATIONS  FOR  LOCAL  ANESTHESIA. 


DANGERS    OF    LOCAL    ANESTHESIA. 

The  dangers  of  local  anesthesia  vary  according  to  the  method 
employed  and  the  care  observed  in  introducing  the  anesthetic.  With 
cocain  substitutes  these  dangers  are  considerably  less  than  with  cocain 
itself.  Whole  volumes  could  be  written  about  the  syndrome  of 
untoward  symptoms  which  cocain  may  produce  in  the  organism. 
"Cocain  is  contraindicated  in  persons  with  diseased  or  weak  heart, 
while  novocain  seems  harmless,  and,  so  far  as  we  know,  can  be  applied 
with  impunity  even  during  pregnancy  and  lactation."     (Williger.) 

Ethyl  Chlorid. — Least  dangerous  is  local  anesthesia  with  ethyl 
chlorid,  which  may  be  used  to  advantage  for  producing  insensibility 
in  pericemental  diseases  of  the  anterior  teeth.  Many  practitioners 
apply  the  ether  spray,  especially  in  children,  for  the  production  of  a 
brief  analgesia.  Only  small  quantities,  however,  should  be  employed, 
as  this  anesthetic  is  by  no  means  harmless  in  children,  and  even  small 
doses  of  it  may  produce  syncope.  It  should  never  be  employed  near 
an  open  flame  or  in  connection  with  a  thermocautery,  owing  to  the 
danger  of  fire. 

In  obstinate  and  unmanageable  children,  and  sometimes  in  intract- 
able adults,  the  induction  of  a  brief  analgesia  is  preferable  to  local 
injection.  These  are  practically  the  only  cases  in  which  nitrous  oxid 
and  oxygen  analgesia,  at  present  so  popular  among  American  dental 
practitioners,  can  compete  with  novocain-suprarenin  anesthesia,  and 
even  these  exceptions  prove  the  rule  of  the  vast  superiority  of  local 
injection,  as  any  one  familiar  with  both  methods  will  attest.     Ether 


100  INDICATIONS  FOR  LOCAL  ANESTHESIA 

analgesia,  according  to  Braun,  is  a  fairly  safe  form  of  narcosis  suitable 
for  short  interventions  such  as  simple  extractions.  The  inhalation  of 
a  few  whiffs  of  ethyl  chlorid  produces  a  brief  condition  resembling 
alcoholic  intoxication,  which  has  led  to  the  erroneous  belief  that  it  is 
the  freezing  of  the  gingivae  which  renders  the  extraction  painless. 

Analgesia  alone  can  be  considered  in  dental  operations  in  com- 
petition with  local  anesthesia,  while  full  anesthesia  should  be  a  thing 
of  the  past  for  the  dentist.  At  any  rate,  it  is  so  rarely  called  for  in 
dental  practice  that  he  need  not  or  cannot  acquire  sufficient  practice 
in  it,  but,  if  demanded,  should  engage  an  expert  anesthetist.  Anal- 
gesia involves  the  disadvantage  that  it  is  not  always  satisfactory, 
inasmuch  as  its  duration  and  depth  are  insufficient  if  the  least  com- 
plication arises  in  extractions,  and  sometimes  excitement  and  frequently 
erotic  or  unpleasant  dreams  occur  in  patients.  For  these  reasons  the 
presence  of  a  third  person  is  imperative.  Local  anesthesia,  on  the 
other  hand,  offers  a  simpler  and  safer  method  of  an  infinitely  wider 
range  of  usefulness,  which  does  not  require  the  services  of  an  assist- 
ant. In  complicated  operations  which  last  more  than  a  few  seconds, 
local  anesthesia  alone  is  indicated,  as  any  one  will  admit  who  has 
witnessed  a  resection  of  a  mandible  under  general  and  one  under 
local  anesthesia.  Local  anesthesia  is  not  only  equivalent  but  far 
superior  to  general  anesthesia. 

Drugs  for  Hypodermic  Injection. — The  possible  danger  from 
hypodermically  injected  drugs  must  always  be  realized,  first,  because 
the  toxic  effects  of  these  solutions  may  be  variable;  second,  because 
an  injection  may  be  followed  by  untoward  sequelae.  Every  local  anes- 
thetic has  a  toxic  action,  and  one  should  never  forget  that  novocain 
also  is  a  poison.  The  employment  of  excessive  doses,  also  an  idio- 
syncrasy on  the  part  of  the  patient,  may  produce  serious  toxic  symp- 
toms. If,  however,  the  operator  has  correctly  judged  the  character 
of  the  surgical  intervention,  the  resistive  power  of  the  patient,  and 
the  maximal  dose,  i.  e.,  the  specific  toxicity  of  his  solution,  he  will  have 
no  accidents  ordinarily,  if  he  has  observed  strict  asepsis. 

Local  Action  of  Novocain. — Locally  the  novocain  solution  recom- 
mended   involves    no    risk    of    tissue    le'sions    whatever.     Even    when 


DANGERS  OF  LOCAL  ANESTHESIA  101 

employed  in  large  quantities,  this  drug  has  an  indifferent  action,  and  is 
very  well  tolerated  by  the  tissues.  Necrosis  used  to  occur  when 
cocain  solutions  of  high  percentage  or  proprietary  preparations 
containing  strongly  escharotic  drugs  such  as  nitric  acid  were  still  in 
vogue. 

Breaking  of  the  Needle. — A  possible  local  accident  to  be  reckoned 
with  is  the  breaking  of  the  hypodermic  needle,  a  fragment  of  which 
sometimes  disappears  so  rapidly  in  the  mucosa  that  it  cannot  be 
found  again.  These  accidents  have  increased  in  number  since  the 
introduction  of  conductive  anesthesia,  and  have  occurred  mostly  in 
mandibular  injection.  In  our  opinion,  very  frequently  lack  of  tech- 
nical skill  and  unfamiliarity  with  the  correct  method  of  procedure 
are  responsible  for  such  accidents.  Only  new  steel  needles,  or  those 
that  have  been  used  but  a  few  times,  should  be  employed;  rusty  ones 
break  easily.  Iridio-platinum  needles  are  far  preferable  for  this,  if 
for  no  other  reason.  Thin  needles,  of  course,  are  more  apt  to  break 
than  stouter  ones,  and,  since  the  break  usually  occurs  at  the  mouth 
of  the  hub,  long  needles  are  safer.  This  risk,  it  is  hoped,  will  be 
eliminated  by  the  use  of  the  trocar  cannula  previously  described. 

The  needle  may,  however,  break  without  the  operator's  fault,  if, 
for  instance,  the  patient  moves  his  head  or  gives  a  sudden  start.  If 
the  needle  fragment  has  been  sterile  and  free  from  rust,  it  seems  to 
heal  in  without  causing  any  trouble,  as  has  been  noted  in  several 
cases.  It  is  quite  possible,  however,  that  complications  may  be  produced 
by  the  fragment  later  on.  In  all  such  cases,  therefore,  an  attempt 
should  be  made  to  remove  it,  after  determining  its  location  by  a 
Rontgenogram . 

If,  in  subperiosteal  injection,  the  operator  has  properly  palpated 
the  tip  of  the  advancing  needle,  he  will,  with  some  experience  in  minor 
oral  surgery,  be  able  to  fix  the  fragment,  and,  after  waiting  for  the 
completion  of  the  anesthesia,  locate  it  by  a  transverse,  never  a  vertical, 
incision  with  a  sharp,  sterile  lancet,  and  pick  it  out  with  sterile  pliers. 
If  this  attempt  is  unsuccessful,  or  if  a  needle  is  broken  during  con- 
ductive anesthesia,  a  surgeon  must  be  summoned  to  extricate  the 
fragment. 


102  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Idiosyncrasy. — Without  any  fault  of  the  operator,  intoxications 
are  sometimes  caused  by  idiosyncrasies,  indisposition,  and  reduced 
power  of  resistance  on  the  part  of  the  patient.  It  is  hardly  possible 
to  know  or  diagnosticate,  in  advance,  the  patient's  disposition  to 
abnormal  reaction  to  certain  drugs.  Some  persons  do  not  tolerate 
cocain  and  exhibit  grave  toxic  symptoms  even  after  the  minutest 
dose.  Others,  again,  are  indifferent  to  large  doses,  which  fail  to  pro- 
duce in  them  the  desired  anesthesia.  Still  others  who  do  not  tolerate 
alypin,  for  instance,  react  perfectly  normally  to  other  salts,  such  as 
novocain,  and  vice  versa. 

Very  frequently,  by  way  of  anamnesis,  the  details  of  such  peculi- 
arities may  be  learned  in  the  same  way,  as  a  hemophiliac  cannot  be 
recognized  at  first  sight,  and  information  must  be  previously  obtained 
from  the  patient  himself. 

At  all  events,  caution  is  required  with  patients  who  complain  of 
palpitation  almost  immediately  after  the  introduction  of  the  needle, 
or  show  a  threatening  color  of  the  face.  In  doubtful  cases  small 
quantities  and  weak  doses  of  the  anesthetic  should  be  employed  at 
the  start.  A  slight  acceleration  of  the  pulse  is  notable  after  every 
injection,  but  usually  it  soon  returns  to  normal. 

Shock  and  Collapse. — Shock  is  of  great  importance  in  anesthesia. 
The  psychic  shock  is  invariably  greater  in  local  than  in  general  anes- 
thesia, the  patients  being  under  the  impression  that  they  are  to  undergo 
an  operation  while  fully  conscious.  In  hysterical  and  highly  nervous 
patients  difficulties  may  be  encountered  in  persuading  them  to  submit 
to  local  anesthesia,  owing  to  their  reduced  resistance  to  psychic  shock. 
They  exhibit  conditions  of  excitement  and  collapse  which  may  assume 
the  proportions  of  syncope.  Serious  hysteria,  therefore,  is  a  contra- 
indication to  local  anesthesia.  Cases  have  been  reported  in  which 
the  patients  collapsed  before  the  injection  and  expired  from  shock 
before  any  anesthetic  whatever  had  been  applied. 

In  nervous  patients  of  low  vital  resistance  and  in  persons  without 
self-restraint  or  courage,  special  persuasion  is  required  to  dissipate  all 
fear  before  the  operation.  In  such  cases  invariable  success  will  be 
assured    only    to    that    operator    who,    by    his    skill,    training,    and 


DANGERS  OF  LOCAL  ANESTHESIA  103 

familiarity  with  the  method  of  procedure  is  capable  of  fully  keeping 
his  promise.  It  is  a  great  mistake  for  any  operator  to  guarantee  full 
success  before  the  operation,  because,  in  case  of  failure,  he  under- 
mines his  reputation  thereby.  Besides  being  most  unprofessional  and 
unscientific,  such  a  guaranty  is  apt  to  arouse  more  suspicion  than 
confidence  in  an  intelligent  patient. 

Antidotes  in  Collapse. — A  number  of  effective  measures  may  be 
adopted  in  case  of  disquieting  symptoms.  In  light  affections,  such  as 
palpitation,  rapid  pulse,  pallor,  perspiration,  and  trembling,  a  decoc- 
tion of  strong  black  coffee,  fresh  aromatic  spirits  of  ammonia,  or  from 
5  to  7  drops  of  camphorated  validol  in  a  little  water  are  administered 
internally;  in  more  serious  affections  amyl  nitrite,  from  i  to  3  drops 
on  a  napkin,  is  given  by  inhalation. 

Validol  is  a  colorless  liquid  of  mild,  agreeable  odor  and  refreshing 
taste.  It  consists  of  menthylester  of  valerianic  acid  with  30  per  cent, 
of  free  menthol  and  10  per  cent,  of  camphor.  It  is  insoluble  in  water, 
but  readily  soluble  in  alcohol,  and,  if  given  internally,  in  doses  of  from 
5  to  7  drops  in  a  tablespoonful  of  water,  constitutes  an  ideal  restorative 
in  serious  cases  of  collapse. 

Amyl  nitrite  is  a  clear,  volatile,  yellow  fluid  with  fruit-like  odor. 
On  inhaling  the  vapor,  flushing  of  the  face  occurs,  the  pulse  is  accel- 
erated, and  vascular  dilatation  in  the  head  and  thoracic  region  is 
produced.  The  increased  blood-supply  to  the  head  and  brain  counter- 
acts the  anemic  condition  present,  and  prevents  collapse. 

Disquieting  symptoms  of  a  lighter  nature  following  injection, 
fainting,  or  syncope  may  be  combated  by  placing  the  head  in  a 
recumbent  position.  In  serious  cases  the  heart  must  be  stimulated; 
the  chest  is  wrapped  in  wet  cloths,  and  cold  douches,  coffee  or  a 
hypodermic  injection  of  oil  of  camphor  are  administered.  A  few  or 
all  of  these  agents  should  be  kept  ready  for  use,  as  immediate 
application  is  essential. 

Injections  may  produce  two  further  unpleasant  sequelae,  namely, 
postoperative  pain  and  hemorrhage. 

Postoperative  Pain. — Postoperative  pain  is  often  due  to  purely 
accidental    conditions    of    the    wound,    i.  e.,    sharp    splinters    of    bone 


104  INDICATIONS  FOR  LOCAL  ANESTHESIA 

remaining  in  an  empty  alveolus,  sloughing  of  the  margins  of  the 
wound,  insufficient  hemorrhage  and  clot  formation  after  excessive 
ischemia,  injection  of  non-isotonic  solutions  or  those  containing  strongly 
toxic  agents,  insufficient  disinfection  of  the  field  of  operation,  infection 
from  extraction  with  unclean  instruments,  or  the  patient's  touching 
the  wound  with  septic  fingers,  also  from  food  debris,  all  of  which  can 
be  averted  by  suitable  precautions. 

While  it  is  irrefutable  that  every  anesthetized  wound  will  pass 
into  a  state  of  more  or  less  pronounced  hyperesthesia,  from  which  it 
returns  to  a  normal  condition  sooner  or  later,  yet  from  personal  experi- 
ence, it  is  safe  to  assert  that,  if  the  anesthetic  solution  has  been  made 
with  Ringer  base,  and  the  injection  correctly  performed,  no  post- 
operative pain  is  to  be  expected.  If  all  the  necessary  precautionary 
measures  have  been  observed,  even  severe  inflammations  of  the 
periosteum  subside  in  due  course  of  time,  after  the  effect  of  the  anes- 
thetic has  worn  off.  "The  claim  that  postoperative  pain  is  more 
severe  in  patients  operated  upon  under  local  anesthesia  than  in  those 
operated  upon  under  general  anesthesia,"  Braun  writes,  "is  contrary 
to  all  our  experiences.  There  are,  of  course,  patients  who  for  various 
reasons  suffer  severe  pain  following  operations,  regardless  of  what 
method  of  anesthesia  might  be  employed.  Local  anesthesia,  however, 
does  not  intensify  such  pain,  but  rather  reduces  its  duration  until 
the  return  of  full  sensibility." 

The  greatest  mistakes  are  made  in  regard  to  asepsis,  for  there  are 
still  many  operators  who  make  an  injection  without  having  previously 
disinfected  the  mucosa.  By  simply  swabbing  with  iodin,  as  described 
above,  the  great  danger  of  infection,  frequently  followed  by  edema, 
is  materially  reduced. 

A.  Cohn,  of  Berlin,  reports  a  case  which  is  interesting  in  this  con- 
nection: "A  patient,  aged  twenty-seven  years,  asked  me  to  extract 
an  upper  third  molar  affected  with  pericementitis.  The  injection  and 
extraction  were  entirely  successful.  About  four  hours  afterward, 
postoperative  hemorrhage  occurred,  with  a  sensation  of  heaviness  in 
the  left  limb.  The  hemorrhage  was  readily  arrested.  The  following 
day    grave    symptoms   of   blood-poisoning    occurred,    combined    with 


DANGERS  OF  LOCAL  ANESTHESIA  105 

paralysis  of  the  left  arm  and  leg,  which  led  me  to  suspect  intoxication 
by  novocain-suprarenin.  This  diagnosis  had  to  be  abandoned,  how- 
ever, when  on  the  following  day  the  right  side  also  became  paralyzed. 
It  was  then  ascertained  that,  despite  careful  injection,  streptococci 
had  caused  embolism  in  the  lumbar  region,  producing  paralysis  of 
the  legs,  which  has  not  yet  disappeared  (two  years  after),  while  the 
other  symptoms  vanished.  This  accident,  therefore,  must  be  regarded 
as  indirectly  due  to  local  anesthesia." 

In  many  cases,  postoperative  pain  after  injection  is  of  psychic 
origin,  as  Cieszynski  has  pointed  out.  His  assertion,  however,  that 
after-pain  most  frequently  follows  pulp  extirpation  under  anesthesia 
is  untenable,  since  the  normal  solution  always  yields  a  most  favorable 
result. 

Fig.   13 


Syringe  for  spraying  novocain  powder. 

Therapeutic  Measures  in  Postoperative  Pain. — Postoperative  pain 
is  prevented  or  counteracted  therapeutically  by  internal  adminis- 
tration of  morphin,  trigemin  (0.25  gram  per  dose),  aspirin  (i  to  3 
tablets),  pyramidon  (0.3  gram  per  dose),  or  combined  doses  of  pyrami- 
don  (o.i  gram)  and  aspirin  (0.3  gram),  or  of  any  two  of  these  drugs. 
Cold  compresses  also  have  proved  most  useful.  In  wounds,  tamponing 
with  pure  novocain  powder  renders  surprisingly  good  service.  In  all 
cases  of  inflammation  of  wounds  novocain  powder  also  can  be  advan- 
tageously applied.  The  cavity  of  the  wound  is  carefully  cleansed  and 
sterilized  with  hydrogen  peroxid  and  a  10  per  cent,  aqueous  solution 
of  chlorphenol,  and  a  layer  of  about  2  mm.  thickness  of  novocain 
powder  (from  0.5  to  i  gram)  is  introduced,  and  a  gauze  tampon, 
saturated  with  10  per  cent,  iodoform,  which  also  has  been  previously 


106  IXDICATIOXS  FOR  LOCAL  AXESTHESIA 

charged  with  novocain  powder,  is  apphed  with  hght  pressure.  For 
some  time  the  writer  has  employed  a  convenient  powder-spraying 
syringe,  from  which,  by  compressing  a  rubber  bulb,  pure  novocain 
is  blown  through  a  hard  rubber  tube  which  is  held  close  to  the  wound 
(see  Fig.  13).  This  procedure  of  disinfecting  and  tamponing  the  wound 
is  repeated  ever}^  twenty-four  hours,  after  which  the  healing  process 
is  left  to  itself  without  any  further  therapeutic  aid.  (See  chapter  on 
Anesthesia  in  the  Therapy  of  Inflammation,  page  129.) 

In  cases  of  severe  inflammation  with  general  depression  due  to 
pain  from  pulpitis  or  pericementitis,  doses  of  morphin  internally  are 
most  favorably  indicated,  especially  if  given  half  an  hour  before  induc- 
tion of  anesthesia  or  extensive  dental  operations.  The  formula  is  as 
follows : 

Morphin 0.2 

Hyoscin 0.005 

Distilled  water 10. o 

From  6  to  8  drops  in  a  tablespoonful  of  water. 

Besides  its  pronounced  sedative  effect,  this  dose  accelerates  the 
wound  healing  and  prevents  reaction.  The  extensive  application  of 
anesthesia  in  the  therapy  of  inflammations  is  especially  indicated  in 
dentistry.  With  this  point  in  view,  the  writer  has  compounded  an 
arsenic  paste  which  contains  arsenous  acid,  novocain,  aa  4;  thymol, 
iodoform,  aa  0.5;  ghxerin,  chlorphenol  crystals,  aa  enough  to  make 
a  paste;  to  be  incorporated  in  asbestos  fiber.  This  paste  has  proved 
most  efficacious  in  the  practice  of  many  operators. 

Postoperative  Hemorrhage. — Postoperative  hemorrhage  caused  by 
injection  is  very  rare  indeed.  It  is  arrested  according  to  the  prin- 
ciples recommended  by  Williger,  the  chief  measure  being  tamponing. 
A  normall}^  bleeding  wound,  however,  should  never  be  dressed  with 
tampons.  Novocain  tamponade  is  applied  only  superficially,  so  that 
the  formation  of  granulating  tissue  or  blood-clot  in  the  fundus  of  the 
wound  is  not  inhibited. 

All  in  all,  the  complications  that  ma}^  arise  during  or  after  local 
anesthesia  are  far  less  numerous  and  not  so  serious  as  those  involved 


THE  OPERATOR'S  RESPONSIBILITY  107 

in  general  anesthesia;  consequently,  the  prognosis  in  the  latter  is  far 
more  uncertain  and  unfavorable  than  in  local  anesthesia. 

Secondary  effects  of  this  nature  are  fewer  in  direct  ratio  as  con- 
ductive anesthesia  is  practised.  As  the  anesthetic  solution  is  deposited 
at  a  distance  from  the  diseased  area,  it  exerts  no  direct  action  there- 
upon. Subperiosteal  injections  are  more  prone  to  cause  trouble, 
because  the  process  of  infiltration,  the  subsequent  anemia,  and  the 
resulting  irritation  of  the  wound,  may  produce  complications.  After 
conductive  anesthesia,  on  the  other  hand,  the  hemorrhage  and  the 
behavior  of  the  tissues  involved  in  the  operation  are  the  same  as  after 
general  anesthesia,  or  when  no  anesthetic  has  been  used. 


THE    OPERATOR'S    RESPONSIBILITY. 

The  patient's  risk  in  local  anesthesia  varies  according  to  the 
operator's  skill,  and  therefore  it  cannot  be  too  strongly  emphasized 
that  local  anesthesia  demands  from  the  operator  a  specially  thorough 
technical  and  scientific  knowledge  which  can  be  acquired  only  by 
practice  and  experience. 

The  operator's  duty  is  specially  exacting,  owing  to  the  fact  that 
he  has  to  be  anesthetist  as  well  as  operator.  Since  the  extent  and  the 
depth  of  the  anesthesia  can  be  calculated  only  by  the  one  who  has 
induced  it,  it  seems  imperative  that  the  operator  himself  should  make 
the  injection.  He  should  always  personally  prepare  and  sterilize  the 
solution,  and  never  leave  this  important  part  of  the  work  to  his  assist- 
ant. This,  of  course,  complicates  his  duties  as  compared  with  an 
operation  performed  under  general  anesthesia,  because  he  must  com- 
bine great  technical  skill  and  ability,  circumspection,  clearness  of 
observation,  and  presence  of  mind  with  wide  experience  and  enthusiasm. 

During  the  operation,  an  assistant  should  carefully  watch  the 
heart  and  lungs  without,  however,  neglecting  the  special  requirements 
and  conditions  of  the  operation  itself.  Besides  having  a  thorough 
knowledge  of  the  surgical  conditions,  the  operator  must  fully  master 
the  anatomy  of  the  field  of  operation.     He  must  know  all  secondary 


108  IXDICATIOXS  FOR  LOCAL  AXESTHESIA 

symptoms  that  may  arise  during  or  after  the  injection,  and,  simul- 
taneously with  the  anesthetic  and  operative  instruments,  must  prepare 
all  the  accessories  necessary  for  emergencies,  such  as  am^'l  nitrite, 
validol,  oil  of  camphor,  and  a  Pravaz  syringe.  By  a  quick  perception 
of  am^  untoward  symptoms  accidents  can  generally  be  prevented  or 
so  counteracted  as  to  avert  serious  danger.  The  chief  s^^mptoms  of 
approaching  danger  are  facial  pallor,  perspiration,  shallow  respiration, 
irregular  pulse,  and  dilatation  of  the  pupils. 

For  these  reasons,  while  waiting  for  the  injected  anesthetic  to 
take  full  effect,  patients  should  never  be  left  in  the  waiting-room 
without  an  attendant,  but  be  kept  under  continuous  observation. 

The  following  alarming  case  has  been  reported,  which  illustrates 
very  well  the  necessity  for  such  precaution:  A  practitioner  had 
injected  2  c.c.  of  a  novocain-suprarenin  solution  by  the  subperiosteal 
method  in  the  maxilla  of  a  woman  who  had  just  recovered  from  influenza. 
The  operator  subsequently  left  the  room  in  order  to  remove  in  the 
laborator^^  the  needle  which  had  become  firml}'  stuck  in  the  syringe. 
Upon  returning  after  not  more  than  one  minute,  he  noted,  to  his 
astonishment,  that  the  patient  had  collapsed,  had  fallen  back  in  the 
chair  and  become  wedged  between  seat,  armrest,  and  back.  The 
head  was  deeph'  reclined,  respiration  was  diflicult  and  slow,  the  pupils 
dilated,  the  facial  color  cyanotic;  in  short,  all  symptoms  typical  of 
approaching  asphyxia  were  present.  With  great  effort  he  lifted  the 
unconscious  patient  from  the  chair  and  laid  her  on  the  floor.  As  res- 
piration ceased,  artificial  respiration  was  induced,  which  proved 
successful  after  about  two  minutes'  eftort.  The  patient  recovered 
relatively  quickl3^  after  cold  cloths,  fresh  air,  and  amyl  nitrite  had 
been  applied,  and  despite  the  serious  character  of  her  collapse  was 
able  to  return  home  by  carriage  an  hour  afterward. 

This  accident  furnishes  convincing  proof  of  the  necessity  of  having 
a  third  person  present  for  assistance  in  ever}'  case  of  local  anesthesia. 

Anamnesis. — The  operator,  before  inducing  anesthesia,  must  ques- 
tion the  patient  concerning  his  heart,  lungs,  and  ner^'ous  condition. 
In  man^^  cases  he  will  thus  be  able  to  obtain  an  accurate  history  and 
gather  the  information  necessary  for  making  his  dispositions  in  regard 


THE  OPERATOR'S  RESPONSIBILITY  109 

to  individualization  in  the  dose  to  be  injected,  calculation  of  the 
time  of  waiting,  etc. 

As  we  have  pointed  out  before,  it  does  not  seem  practical  for  the 
dentist  to  make  a  thorough  examination  by  way  of  auscultation  and 
percussion,  nor  is  an  absolutely  certain  diagnosis  necessary,  because 
the  solution  advocated  never  imperils  the  patient's  life.  Individual 
peculiarities  must,  of  course,  be  duly  considered,  and  no  factor  tending 
to  a  successful  injection  should  be  slighted. 

Harmlessness  of  the  Normal  Solution. — In  some  cases  it  may  be 
difficult  to  decide  whether  local  or  general  anesthesia  is  more  favorably 
indicated.  In  arteriosclerosis  and  nephritis  great  hesitancy  has  here- 
tofore been  entertained  toward  injecting  anesthetic  solutions;  in  the 
former  disease,  owing  to  the  altered  condition  of  the  vascular  walls, 
which  often  do  not  tolerate  even  a  moderate  change  in  blood-pressure 
such  as  is  produced  by  suprarenin;  in  the  latter  disorder,  owing  to 
the  danger  of  intoxication  involved  in  the  passage  of  the  anesthetic 
through  the  diseased  kidney. 

The  weak  0.5  and  i  per  cent.,  even  the  1.5  per  cent,  novocain 
solutions,  with  their  small  additions  of  suprarenin,  must  be  regarded 
as  agents  which  in  such  cases,  even  in  diabetics,  render  excellent 
service  and  involve  no  risk  to  the  life  or  health  of  the  patient. 

From  these  observations  it  appears  that  the  anesthetist  has  a 
great  responsibility,  being  liable  for  the  slightest  injury  inflicted  by 
his  negligence  upon  the  patient.  A  perfect  mastery  of  the  science 
and  technique  of  local  anesthesia  is  an  essential  consideration  in  order 
that  the  operator's  conscience  may  be  clear  in  regard  to  the  proper 
fulfilment  of  his  duty. 

To  be  safe  in  case  of  any  accidents,  the  findings  of  the  examination, 
and  the  composition,  dosage,  and  quantity  of  the  solution  injected 
should  always  be  charted.  Such  a  record  is  the  best  proof  for  the 
operator's  conscientiousness,  and  is  of  paramount  importance  in  case 
of  legal  complications. 


110  IXDICATIOXS  FOR  LOCAL  A  X  EST  H  ESI  A 


ACCIDENTS    FOLLOWING    NOVOCAIN    INJECTIONS. 

Serious  intoxications  after  injection  of  novocain  solution  have 
never  been  observed  b>'  the  writer  personally,  unless  he  were  to  regard 
a  case  of  narcotic  slumber  as  one  of  dangerous  intoxication.  The  case 
referred  to  was  as  follows: 

Narcotic  Slumber  Following  Novocain  Injection. — Before  extracting 
the  gangrenous  roots  of  a  lower  second  molar  in  a  strong  and  healthy 
woman,  aged  thirty-six  3'ears,  local  anesthesia  of  the  mucosa  was 
induced;  3  c.c.  of  a  2  per  cent,  novocain-thymol  solution,  as  employed 
at  that  time,  were  injected,  3  drops  of  fresh  synthetic  i  in  1000  supra- 
renin  solution  having  been  added  immediately  before  injection.  The 
injection,  as  in  all  patients  of  strong  constitution,  was  completed  without 
pain.  The  period  of  waiting  for  the  establishment  of  perfect  anesthesia, 
owing  to  the  tardiness  of  diffusion  in  the  mandible,  was  calculated  at 
fifteen  minutes;  in  the  meantime  two  cavities  in  upper  teeth  on  the 
same  (left)  side  were  to  be  excavated.  Very  soon  (about  one  minute) 
after  the  injection,  the  patient  noted  considerable  numbness  in  the 
entire  left  mandible,  similar  to  that  produced  by  conductive  anes- 
thesia, and  live  minutes  afterward  could  no  longer  feel  the  touch  of 
the  rinsing  glass  on  that  side  of  the  lip.  The  vascular  S3'stem  was 
affected  at  the  same  time  by  a  slight  acceleration  in  pulse,  lasting  for 
two  or  three  minutes,  whereupon  the  patient  lapsed  into  a  condition 
of  semi-slumber  or  light  sopor,  and  exhibited  difficult}^  in  keeping 
her  mouth  open.  Pulse  and  respiration  soon  resumed  their  normal 
rate,  and  the  patient  seemed  to  be  sleeping  comfortably.  As  in  hyp- 
notic sleep,  she  answered  every  question,  rinsed,  opened,  and  closed 
her  mouth  as  requested,  in  short,  followed  all  directions,  without, 
however,  opening  her  eyes  or  being  conscious  of  her  actions.  The 
two  cavities,  after  painless  excavation,  despite  close  proximit}-  to  the 
pulp,  were  filled  with  amalgam  inserted  over  a  protective  cement 
step.  In  the  meantime  twent}^  minutes  had  elapsed  since  the  injec- 
tion, and  the  two  badl^^  carious  roots  were  extracted.  Immediately 
afterward  the  patient  suddenly  straightened  herself  up  with  a  start, 


ACCIDENTS  FOLLOWING  NOVOCAIN  INJECTIONS  111 

opened  her  eyes  and,  according  to  directions,  vigorously  rinsed  the 
mouth.  From  this  moment  she  assumed  an  entirely  changed  attitude, 
acted  perfectly  normally,  and  stated  that  a  pain  as  from  pressure  had 
startled  her.  She  still  felt  the  numbness  in  the  left  side  of  the  man- 
dible, and  was  almost  ashamed  when  told  of  having  been  asleep.  She 
boasted  of  always  having  enjoyed  an  exceptionally  strong  constitution, 
and,  as  if  to  excuse  herself,  mentioned  that  her  system  reacted  with 
extraordinary  readiness  and  intensity  to  any  medicament.  To  this 
peculiarity  she  ascribed  the  slumber  following  the  injection,  saying 
that  the  normal  dose  evidently  had  affected  her  very  strongly.  She 
did  not  know  what  operations  had  been  made  in  her  mouth,  and  was 
glad  to  hear  that  her  upper  bicuspids  had  been  filled  in  the  meantime. 
She  left  in  normal  possession  of  her  senses  and  feeling  quite  well,  and 
experienced  no  further  after-effects. 

In  the  writer's  opinion,  this  case  of  brief  "hypnotic"  slumber  was 
due  exclusively  to  the  action  of  the  novocain  and  the  unusual  suscep- 
tibility of  the  patient.  No  erotic  symptoms  were  noted  in  this  case, 
such  as  are  frequently  observed  in  general  anesthesia,  also  sometimes 
in  local  anesthesia  with  ethyl  chlorid  or  cocain.  Nevertheless,  such 
symptoms  may  occur  in  sexually  highly  excitable  individuals  after 
novocain  injection,  which  again  justifies  the  demand  that  not  only 
during  general  but  also  during  local  anesthesia  a  third  person  should 
be  present  to  avoid  all  risks  of  suspicion. 

Since  the  patient's  excellent  state  of  health  in  the  case  cited  was 
corroborated  by  her  physician,  the  writer  is  inclined  to  consider 
the  extraordinary  effect  of  the  novocain  as  a  mild  intoxication,  or 
rather  an  irritation  of  the  central  nervous  system,  produced  by  the 
exceedingly  small  quantity  of  0.06  novocain. 

Toxic  Action  of  Novocain. — It  is  remarkable  that  in  the  above 
case  there  appeared  none  of  the  heretofore  observed  phenomena  of 
intoxication  by  novocain,  which  Liebl  has  endeavored  to  test  in  his 
own  body.  Upon  injecting  0.75  gram  of  a  warm  10  per  cent,  solution 
in  his  right  thigh,  this  investigator  noted,  after  four  minutes,  "a 
sudden,  strange  warmth  in  the  entire  body,  especially  in  the  region 
of  the  liver,  slight  malaise,  symptoms  of  nausea,  and  general  agitation. 


112  INDICATIONS  FOR  LOCAL  ANESTHESIA 

but  no  notable  change  in  pulse  or  complexion.  Two  minutes  later 
slight  deafness  in  the  left  ear  set  in;  also  ocular  disturbances;  accom- 
modation in  both  eyes,  especially  in  the  left,  being  possible  only  with 
great  effort;  and  diplopia.  Thirteen  minutes  after  the  injection  slight 
pungent  headache  on  the  left  side  was  noted;  after  seven  additional 
minutes,  paresthesia  in  the  region  supplied  by  the  radial  nerve  on  the 
left  side."  After  about  half  an  hour  of  general  malaise  normal  ease 
returned. 

The  slight  acceleration  of  pulse  shortly  after  injection,  as  noted 
in  the  case  reported  by  the  writer,  is  perhaps  to  be  attributed  to  the 
suprarenal  extract  rather  than  to  the  anesthetic,  since  it  has  not  been 
observed  in  pure  novocain  solutions.  Liebl  also  emphasizes  that 
in  his  own  case  no  change  in  pulse  and  complexion  was  noted. 

It  is  interesting  and  important  to  note  that  even  novocain, 
although  it  is  almost  devoid  of  irritating  action  on  the  tissues,  and 
can  be  tolerated  even  pure  without  disturbances,  if  applied  topically 
and  externally,  may  occasionally  produce  irritation  of  the  central 
nervous  system,  even  in  a  dosage  far  below  the  maximal.  On  the 
other  hand,  it  must  not  be  overlooked  that  an  organism  which  reacts 
even  to  the  lightest  chemical  stimuli,  and  in  which  the  protoplasm  is  ex- 
tremely sensitive,  as  in  the  case  reported,  will  tolerate  a  maximal  dose 
of  novocain  only  far  below  the  average.  To  cite  Braun:  "Whether 
and  in  what  intensity  novocain  intoxication  occurs  in  the  central 
nervous  system  by  no  means  depends  only  upon  the  dose  of  novocain 
introduced  into  the  blood,  but  also  upon  the  time  allowed  for  its 
introduction.  If  introduced  into  the  blood  suddenly,  or  in  concen- 
trated solution — in  the  reported  case  the  injected  solution  exceeded 
in  its  action  that  of  the  usual  maximum  dose — immediate  toxic 
action  may  result  from  a  dose  which,  if  administered  gradually,  i.  e., 
in  dilute  solution,  or  in  portions  at  intervals,  may  not  produce  even 
the  slightest  suggestion  of  an  intoxication  of  the  central  nervous 
system,  because  then  the  concentration  of  the  novocain  in  the  capillaries 
of  this  organ  will  at  no  time  exceed  the  toxic  dose." 

Klein  also  claims  to  have  observed  pronounced  symptoms  of 
intoxication  from  novocain  in  five  cases,  three  of  which  he  attributes 


ACCIDENTS  FOLLOWING  NOVOCAIN  INJECTIONS  113 

to  complication  with  functional  disorders  of  the  heart,  lack  of  resistance 
of  the  whole  organism,  and  abnormal  menstruation.  In  his  other  two 
cases,  however,  he  regards  novocain  as  exclusively  responsible  for 
serious  symptoms  of  collapse.  Just  as  the  case  reported  by  the  writer 
seems  to  illustrate  an  instance  of  extraordinary  action  of  novocain 
solution  that  must  be  judged  by  itself,  so  the  two  cases  of  intoxica- 
tion reported  by  Klein,  which  apparently  cannot  be  ascribed  to  any 
other  causes,  must  be  regarded  as  abnormal  exceptions  to  the  rule. 
From  his  own  experience  with  the  use  of  novocain,  now  extending 
over  a  period  of  eight  years,  the  writer  can  only  once  more  emphasize 
its  eminent  advantages  over  cocain,  even  though  novocain,  as  we  have 
seen,  may  occasionally  produce  untoward  secondary  effects.  Until 
now  these  cases  have  been  of  such  a  mild  or  trivial  nature,  and  so 
far  above  comparison  with  cocain  cases,  that  novocain  loses  none  of 
its  great  superiority  in  regard  to  the  relatively  almost  complete  absence 
of  irritation.  A  local  anesthetic,  as  Liebl  has  definitely  established, 
"surely  possesses  extremely  favorable  properties,  if,  like  novocain, 
it  only  occasionally  produces  relatively  harmless  symptoms  of  slight 
intoxication,  which  cannot  be  compared  for  one  minute  with  the 
ghastly  clinical  picture  of  cocain  intoxication,  and  does  it  only  under 
conditions  specially  favorable  for  the  appearance  of  symptoms  of 
absorption,  that  is,  at  body  heat,  and  only  in  the  high  dose  of  0.75 
gram  of  a  10  per  cent,  solution,  which  is  never  employed  in  local  anes- 
thesia." Cases  of  intoxication  from  novocain  are  very  exceptional, 
and  no  great  importance  can  be  attached  to  them,  since  in  the  vast 
majority  the  experiences  with  this  drug  have  been  extraordinarily 
favorable,  as  Klein  fully  acknowledges. 

Cases  of  gangrene  and  necrosis  following  novocain-suprarenin 
injections,  which  have  now  and  then  been  reported,  have  in  every 
case  been  traced  to  stale  and  infected  solution,  lack  of  sterility  of 
the  instrumentarium,  and  injudicious  injection  directly  into  a  focus 
of  infection.  This  last  cause  is  also  responsible  for  the  "case  of  novo- 
cain peridental  anesthesia  followed  by  unpleasant  symptoms,"  as 
reported  by  John    S.   Marshal V   in  which  0.09  gram  of  a  novocain- 

'  Items  of  Interest,  March,  1914,  p.  220. 


114  INDICATIONS  FOR  LOCAL  ANESTHESIA 

suprarenin  solution  had  been  injected  peridentally  for  the  extraction 
of  two  molar  teeth  affected  with  pyorrhea  alveolaris.  Granted  that 
every  step  in  the  operation  was  performed  under  strictly  aseptic  con- 
ditions, granted  even  that  the  solution  which  was  prepared  from 
novocain-adrenalin-sodium-chlorid  tablets  which  have  proved  extremely 
unstable,  was  perfect,  the  symptoms  of  malaise,  constriction  in  the 
region  of  the  heart,  labored  breathing,  and  increase  in  pulse  rate 
which  were  noted  on  the  day  following  the  operation  are  clearly  those 
of  mild  septicemia  due  to  the  bacteria  carried  from  the  pyorrheal  area 
into  the  blood  by  the  needle  and  the  injected  fluid,  but  not,  as  Mar- 
shall suspects,  manifestations  of  the  cumulative  effect  of  novocain. 
Statements  regarding  accidents  due  to  the  toxicity  of  novocain, 
especially  those  appearing  in  the  lay  press,  should  invariably  be 
accepted  with  a  grain  of  salt,  inasmuch  as  the  case  histories  given  are 
rarely  complete  and  intelligible  enough  to  enable  the  expert  to  draw 
his  own  conclusions  as  to  the  real  cause  or  causes.  Such  reports 
usually  contain  statements  and  inferences  prejudicial  to  novocain, 
which  should  be  carefully  verified  before  acceptance.  As  the  British 
Journal  of  Dental  Scieyice^  aptly  remarks,  editorially:  "The  dental 
and  medical  world  have  for  a  considerable  time  regarded  novocain 
as  an  ideal  local  anesthetic,  because,  if  injected  with  proper  aseptic 
precautions,  it  involves,  so  far  as  we  know  at  present,  no  risk  whatever 
to  the  patient.  An  anonymous  correspondent  to  our  contemporary 
{The  Times)  complains  of  an  immediate  effect  upon  the  heart,  'a 
tingling  sensation  of  the  nerves  near  the  region  of  the  heart,'  followed 
after  an  hour  by  'a  bad  heart  attack,'  accompanied  by  a  sense  of 
suffocation  and  intense  pain,  and  during  the  subsequent  two  months 
several  similar  attacks,  ending  in  a  nervous  breakdown.  Before  these 
experiences  can  be  of  any  service  in  extending  our  knowledge  of  the 
effects  of  novocain,  many  things  will  be  necessary.  We  shall  require 
to  know  all  about  the  general  anesthetic  that  was  administered  just 
before  the  novocain  was  injected,  what  was  the  exact  nature  of  the 
preparation  employed,  its  strength,  and  whether  it  was  freshly  pre- 
pared; whether  any  of  the  ritual  of  asepsis  was  omitted,  and,  most 

'  March  i6,  1914. 


ACCIDENTS  FOLLOWING  NOVOCAIN  INJECTIONS  115 

important  of  all,  we  must  know  from  some  reliable  medical  authority 
the  condition  of  the  patient's  cardiovascular  system.  No  doubt  the 
'Reader  of  The  Times'  was  quite  unaware  of  the  fact  that  no  single 
injection  of  novocain  ever  has  or  ever  could  produce  consequences 
lasting  two  months.  Septic  poisoning  might  possibly  have  a  lingering 
sequel,  though  recurrent  heart  attacks  could  scarcely  constitute  the 
symptoms  even  in  such  a  case.  Some  of  the  writer's  expressions 
would  be  explained  by  an  attack  of  angina,  but  from  a  perusal  of  the 
letter  and  without  further  information  we  should  unhesitatingly 
refuse  to  believe  that  an  injection  of  novocain  had  anything  whatever 
to  do  with  the  sequelae."  After  citing  similar  reports,  the  Journal 
continues:  "The  interest  of  these  letters  is  chiefly  this:  that  while 
they  attribute  amazing  consequences  to  an  injection  of  novocain, 
and  can  hardly  be  expected  to  lead  to  any  really  useful  result,  they 
may  cause  widespread  mischief  to  the  community  by  raising  a  ground- 
less panic  with  reference  to  the  use  of  a  very  valuable  and,  when 
properly  employed,  a  very  safe  local  anesthetic.  If  such  loose  appre- 
ciations of  the  nature  of  cause  and  effect  are  allowed  to  disturb  the 
public  mind,  then  every  sufferer  from  gastric  trouble  and  consequent 
cardiac  symptoms  traceable  to  another  cause  will  be  able  to  find  an 
explanation  of  months  of  trouble  in  one  injection  of  novocain,  and 
possibly  this  may  prove  a  more  convenient  explanation  for  circulation 
in  the  family  circle."  To  this  we  might  add  that  it  is  extremely 
unfair  to  the  patient  and  to  the  science  of  local  anesthesia  if  a  dental 
practitioner,  as  occurs  occasionally,  attempts  to  cover  up  his  own 
omissions  and  commissions  in  an  untoward  case  by  laying  the  blame 
on  the  "toxicity  of  the  drug." 

Personally,  in  a  practice  comprising  over  30,000  cases,  the  writer 
has  not  experienced  a  single  instance  of  serious  intoxication  following 
injection,  while  he  will  ever  remember  several  grave  accidents  which 
came  to  his  notice  after  cocain  injections.  The  few  interesting  obser- 
vations of  abnormal  action  of  novocain  merely  corroborate  the  old 
postulate  of  individual  discrimination  in  the  administration  of  every 
drug.  Cocain  very  frequently  produces  general  disorders,  and  local 
gangrenous  conditions  in  the  injected  tissue,  especially  if  the  solution 


116  INDICATIONS  FOR  LOCAL  ANESTHESIA 

was  not  absolutely  pure.  These  conditions  have  never  been  noted 
after  injections  of  novocain,  which  only  in  very  rare  cases  are  followed 
by  postoperative  pain,  which  with  cocain  is  almost  the  rule. 

Hysterical  Spasms  Following  Novocain  Injections. — Several  cases 
of  hysterical  spasms  following  novocain  injection  have  been  reported, 
one  by  Kehr,^  one  by  Knoche,  of  Gotha,  and  one  by  Jelonek,  of  Duis- 
burg.  In  all  these  cases  the  patients  were  subject  to  hysteria,  which 
broke  out  under  the  added  stimulus  of  the  novocain  injections.  In 
the  last  case  reported,  the  patient  had  tolerated  novocain  very  well  on 
former  occasions,  which  proves  that  the  novocain  produced  no  spe- 
cifically toxic  effect,  but  was  merely  the  final  contributing  factor  to 
a  long-preparing  new  outbreak  of  hysteria,  the  predisposition  to  which 
was  greatly  enhanced  at  the  time  of  the  last  injection,  while  during 
previous  injections  the  disease  had  lain  dormant.  All  the  details  of 
this  last  case  confirm  our  opinion  of  the  infinitesimal  danger  of  intoxi- 
cation from  novocain,  which  has  been  found  to  be  and  for  the  present 
remains  the  best  and  least  toxic  anesthetic.  Its  relative  toxicity, 
to  quote  Braun  once  more,  "is  incomparably  smaller  than  that  of  all 
heretofore  known  local  anesthetics;  for  the  extraction  of  teeth,  there- 
fore, this  drug  is  most  favorably  indicated." 

These  case  reports  corroborate  what  has  already  been  demon- 
strated, namely,  that  even  entirely  harmless  doses  of  novocain  occasion- 
ally may  act  toxically  by  eliciting  an  outbreak  of  already  established 
nervous  diseases,  especially  of  hysteria.  These  outbreaks,  however, 
would  have  been  induced  by  any  other  nerve  irritation.  The  proced- 
ure of  injection  and  operation  in  itself  is  an  unusual  experience  which, 
for  a  highly  excitable  patient,  it  is  difficult  or  impossible  to  overcome. 
In  hysteria,  therefore,  as  has  been  said  before,  special  precaution  is 
required  on  the  part  of  the  operator. 

Unduly  Prolonged  Duration  of  Local  Anesthesia. — Several  cases 
of  anesthesia  lasting  for  weeks  or  months  and  extending  over  smaller 
or  larger  areas  have  been  reported,  and  again  it  was  possible  to  prove 
that  these  most  disagreeable  after-effects  were  not  due  to  any  toxicity 
of  the  novocain-suprarenin  solution,  but  to  surgical  injury  of  a  nerve 

1  Deutsche  Monatsschrift  fur  Zahnheilkunde,  January,  1910. 


ACCIDENTS  FOLLOWING  NOVOCAIN  INJECTIONS  117 

trunk  inflicted  accidentally,  especially  during  the  extraction  of  teeth 
with  abnormal  roots.  The  therapeutic  measures  in  these  cases  con- 
sisted in  electric  treatment  and  massage  of  the  muscles  of  masti- 
cation, with  the  object  of  stimulating  the  regeneration  of  the  injured 
nerve. 

One  case  of  brief  temporary  paralysis  of  the  facial  nerve  also  has 
been  reported.  In  a  review  of  these  unusual  dental  cases,  Braun 
writes:  "Our  surgical  literature  contains  no  reports  of  novocain  intoxi- 
cations, although  we  are  daily  using  infinitely  greater  quantities  than 
have  been  used  in  the  cases  in  question ;  to  mention  only  a  few  examples 
of  operations  which  for  years  have  been  performed  by  many  surgeons 
under  novocain  anesthesia  exclusively:  In  hemorrhoid  operations  we 
regularly  inject  lOO  c.c.  of  a  0.5  per  cent,  solution,  in  hernia  operations 
from  100  to  150  c.c,  in  excisions  of  goitre  from  100  to  150  c.c,  in 
resections  of  the  maxilla  from  10  to  20  c.c  of  a  i  per  cent.,  and  75 
c.c  of  a  0.5  per  cent,  solution.  Quantities  of  from  150  to  200  c.c  of  a 
0.5  per  cent,  solution,  I  have  injected  in  hundreds  of  patients  of  every 
constitutional  variety  imaginable.  Hesse,  of  Stettin,  uses  up  to  250 
c.c,  Borchardt  and  Axhausen  150  c.c,  the  Heidelberg  Surgical  Clinic 
50  c.c.  of  a  I  per  cent,  solution,  each  c.c  of  solution  containing  0.00012 
gram  suprarenin.  Neither  myself  nor  other  surgeons  have  noted 
any  after-effects  except  occasionally  a  single  attack  of  vomiting  after 
injection  of  very  large  doses. 

"It  was  only  recently  that  I  observed  novocain  intoxications  in 
experiments  with  sacral  anesthesia,  in  which  25  c.c  of  a  2  per  cent, 
novocain  solution  with  suprarenin  admixture  were  injected  into  the 
sacral  canal.  In  some  of  these  cases  secondary  effects  were  noted 
very  soon  after  the  injection,  consisting  in  collapse,  vomiting,  and 
other  disturbances  which  passed  off  within  an  hour.  Owing  to  these 
experiences,  I  have  discontinued  these  experiments.  These  observa- 
tions, however,  as  well  as  those  made  in  spinal  anesthesia  are  not 
applicable  to  local  anesthcvsia,  because  the  anesthetic  is  applied  in 
an  entirely  different  way.  It  is  unreasonable  to  think  that  novocain 
when  injected  into  the  gingivae  should  act  differently  than  when  intro- 
duced into  soft  tissue  in  any  other  part  of  the  body.     The  peculiar 


118  INDICATIONS  FOR  LOCAL  ANESTHESIA 

phenomena  which  some  dentists  have  observed  here  and  there  after 
injections  of  very  small  doses  cannot  be  attributed  to  novocain. 

"It  is  sheer  nonsense  to  compare  novocain  with  cocain.  First  of 
all,  its  low  toxicity  has  been  distinctly  proved  by  pharmacological 
investigations;  again,  how  is  it  that  we  can  inject  such  large  doses 
of  novocain  every  day  with  impunity? 

"The  case  of  unduly  prolonged  anesthesia  mentioned  can  in  my 
opinion  be  explained  only  as  being  due  to  hysteria.  Pharmacologists 
have  proved  the  innocuousness  of  novocain  to  nerve  tissue  in  contra- 
distinction to  stovain,  therefore,  whenever  possible,  we  inject  directly 
into  nerve  trunks." 

It  might  also  be  suggested  that  the  case  of  unduly  prolonged 
anesthesia,  as  cited,  might  be  due  to  alcohol  having  been  left  in  the 
syringe  and  injected  together  with  the  anesthetic  solution  (cf.  page  89). 

"At  any  rate,"  Braun  says  in  his  text-book,  "all  such  observations 
teach  us  that  even  the  smallest  operative  interference,  no  matter  how 
carefully  we  proceed,  may  lead  to  dangerous  complications  which  in 
all  probability  are  due  not  to  one  single  cause,  but  to  an  unfortunate 
combination  of  sometimes  inexplicable  conditions." 

INDICATIONS    FOR    LOCAL    ANESTHESIA. 

The  question  as  to  when  local  anesthesia  is  indicated  cannot  be 
solved  within  the  limitations  of  this  book,  as  this  depends  more  or 
less  upon  the  conditions  presented  in  each  case.  For  the  dentist  local 
anesthesia  offers  a  wide  field  of  application,  and  in  its  present  state 
of  perfection  furnishes  an  invaluable  addition  to  his  resources.  As 
long  as  major  surgery  is  rapidly  adopting  local  anesthesia  more  and 
more  generally,  dentistry,  as  a  branch  of  minor  surgery,  should  surely 
employ  this  method  universally.  The  possibility  of  local  anesthesia 
should  always  be  considered  before  resorting  to  general  anesthesia, 
and  not  vice  versa,  as,  unfortunately,  many  dentists  are  still  in  the 
habit  of  doing. 

Oral  Surgery. — In  oral  surgery,  local  injection  can  be  employed 
in  an  infinite   number  of   operations  which  it  is  needless  to  discuss 


INDICATIONS  FOR  LOCAL  ANESTHESIA 


119 


here  in  detail.  Besides  extractions,  all  incisions  in  the  mucosa,  resec- 
tions of  roots,  bone  chiselling,  cyst  operations,  partial  resections, 
extirpation  of  small  tumors,  setting  of  fractures,  etc.,  come  under 
this  heading.  In  all  such  surgical  operations,  before  inducing  anes- 
thesia, the  patient's  head  is  protected  with  the  head  wrap  indicated 
by  J.  Witzel.  A  sterilized  napkin  is  laid  over  the  hair  and  fixed  at 
the  neck  with  a  safety-pin  (see  Fig.  14). 

Fig.  14 


Head  wrap,  designed  by  J.  Witzel. 


Anesthesia  of  Pulp  and  Dentin. — Several  writers  have  recom- 
mended the  method  of  injection  for  anesthesia  of  the  pulp  or  the 
dentin.  Its  application  in  the  conservative  treatment  of  teeth  is, 
indeed,  most  opportune.  The  principles  governing  the  technique  of 
anesthesia  are  the  same  in  conservative  interventions  as  in  the  surgical 
measures  enumerated. 


120  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Pressure  Anesthesia. — A  number  of  measures  have  been  suggested 
for  the  direct  anesthetization  of  the  pulp  and  the  dentin,  without 
injection.  Among  other  things,  novocain-suprarenin  pluglets  and 
alypin  pluglets  are  offered  in  the  market  for  this  purpose,  which  in 
hypersensitive  dentin  often  yield  very  satisfactory  results.  One  of 
these  pluglets  is  either  rubbed  with  a  round-headed  instrument  into 
the  area  of  hypersensitive  dentin,  or  introduced  into  the  moist  cavity, 
pressure  being  exerted  with  a  suitably  shaped  instrument  for  from 
five  to  ten  minutes.  In  cases  of  close  proximity  or  exposure  of  the 
pulp,  full  anesthesia  can  sometimes  be  obtained  by  several  applications. 
For  desensitizing  hypersensitive  dentin  in  the  preparation  of  a  cavity, 
however,  this  method  of  direct  anesthesia  is  extremely  uncertain,  and 
the  operator  is  often  obliged  to  resort  to  injection  which  in  the  great 
majority  of  cases  affords  absolute  painlessness. 

The  anesthesia  for  the  purpose  of  conservative  treatment  in  many 
cases  must  be  more  profound  than  that  for  surgical  purposes.  It  has, 
for  instance,  been  observed  that  under  mandibular  anesthesia  the 
extraction  of  a  tooth  was  absolutely  painless,  yet  the  sensitivity  of 
the  pulp  of  an  approximating  tooth  on  the  anesthetized  side  was  not 
entirely  abolished.  In  all  dentinal  anesthesias,  therefore,  either  the 
usual  amount  of  the  anesthetic  solution  is  increased  by  one-third,  or 
the  concentration  of  the  solution  is  raised  by  using  3  instead  of  2  tablets, 
thereby  insuring  an  almost  certain  effect.  For  the  sake  of  complete- 
ness, we  shall  briefly  describe  a  method  which  seems  most  suitable  for 
pressure  anesthesia,  and  with  which  every  dental  practitioner  is  familiar. 
Griffin^  prefers  for  pressure  anesthesia  hypodermic  tablets  containing 
cocain,  morphin,  and  atropin.  One-third  or  one-half  tablet  is  intro- 
duced in  the  cavity  on  a  minute  cotton  pellet  saturated  with  adrenalin, 
and  allowed  to  lie  on  the  exposed  pulp  for  a  few  seconds.  Then  a  piece 
of  unvulcanized  rubber  slightly  smaller  than  the  cavity  is  laid  over  this 
pellet,  and  gentle  pressure  is  exerted  (see  Fig.  15).  If  the  patient  shows 
the  least  sign  of  pain,  the  pressure  is  relinquished,  to  be  again  gradually 
increased,  without,  however,  causing  any  pain.  In  approximal  cavities 
the  rubber  is  first  firmly  pressed  against  the  cavity  margins,  and  then 

1  Ergebnisse  der  Gesammte  Zahnheilkunde,  1910,  vol.  iii. 


INDICATIONS  FOR  LOCAL  ANESTHESIA 


121 


slightly  against  the  pulp.  Small  round-headed  instruments  are  not 
suitable  for  this  purpose,  as  they  pierce  the  rubber  and  do  not  permit 
of  uniform  pressure.  Only  flat,  broad  pluggers  should  be  used,  as 
they  can  easily  be  lifted  without  displacing  the  rubber.  After  from 
one  to  three  minutes,  when  the  pressure  is  no  longer  painful,  rubber 
and  cotton  pellet  are  removed,  the  opening  into  the  pulp  chamber  is 
enlarged,  and  the  pulp  can  then  be  immediately  extirpated  without 

Fig.  15 


Pliers 


^         Unvulcanised 
rubber 

Cotton  with 
J I  suprarenin 

"Pure  novocain 
-Pulp 


Pressure  anesthesia  in  exposure  of  the  pulp. 

pain  or  hemorrhage.  A  repetition  of  this  pressure  anesthesia  within 
the  pulp  chamber  is  rarely  necessary.  This  method  is  most  con- 
venient in  exposed  pulps,  though  it  is  efficacious  even  when  the  pulp 
is  still  covered  with  a  thin  layer  of  dentin.  A  drop  of  adrenalin,  a  few 
cocain  crystals,  a  drop  of  formagen,  and  pressure  with  rubber  is  all 
that  is  required. 

"For   pressure   anesthesia,"    Riethmiiller^   writes,    "small   rods   or 
pluglets  containing  o.oi  gm.  novocain  and  0.0002  gm.  suprarenin  are 


'  Dental  Cosmos,  February,  1913. 


122  INDICATIONS  FOR  LOCAL  ANESTHESIA 

in  the  market.  These  rods  are  apphed  in  the  same  way  as  the  cocain 
rods  sold  for  this  purpose.  The  anemia  produced  by  the  suprarenin 
allows  of  a  cleaner  operation  with  less  danger  of  subsequent  discolora- 
tion of  the  tooth,  and  is  specially  appreciated  in  children's  teeth  with 
large  apical  foramina.  These  rods  produce  perfect  results  even  in 
advanced  stages  of  pulpitis  and  in  cases  of  pulp-stones,  in  which  the 
familiar  procedure  may  have  to  be  repeated  once  or  twice.  The  great 
advantage  of  these  novocain-suprarenin  rods  over  cocain  or  arsenous 
oxid  lies  in  the  absence  of  pericementitis  following  pulp  extirpation." 

For  confining  the  anesthetic  in  the  cavity  and  distributing  the 
pressure  evenly,  Riethmiiller  recommends  the  use  of  weighted  rubber, 
which  he  finds  far  superior  to  ordinary  unvulcanized  rubber.  In  his 
opinion  cocain  involves  some  risk,  even  when  used  for  pressure  anes- 
thesia, in  patients  with  an  idiosyncrasy,  as  is  illustrated  by  the  follow- 
ing clinical  case:  A  student  in  our  Dental  Infirmary,  while  attempting 
pressure  anesthesia  in  the  lower  left  second  bicuspid  of  a  young, 
healthy-looking  woman,  accidentally  dropped  a  very  small  crystal 
of  cocain  on  the  patient's  tongue,  but  immediately  picked  it  up  with 
cotton  pliers,  and  requested  the  patient  to  rinse  to  remove  the  bitter 
taste  of  which  she  was  complaining.  After  rinsing,  the  patient's 
extremities  began  to  tremble,  her  pupils  were  dilated,  breathing  became 
labored,  and  in  less  than  two  minutes  the  typical  syndrome  of  symp- 
toms of  cocain  intoxication  was  noted.  Restorative  measures  were  at 
once  applied,  as  the  patient  threatened  to  collapse.  Not  until  one  full 
hour  afterward  was  she  able  to  leave  the  infirmary,  accompanied  by 
an  assistant,  owing  to  her  weakened  condition.  Upon  her  return  to 
the  Infirmary  several  days  afterward,  she  gave  a  history  of  hysteria, 
and  stated  that  malaise  had  persisted  for  several  hours.  In  this  case 
of  extreme  susceptibility,  the  application  of  cocain  to  the  pulp  would 
in  all  probability  have  produced  similar  symptoms.  The  pulp  was 
subsequently  extirpated  after  devitalization  by  arsenous  oxid. 

Injection  Indicated  for  Anesthesia  of  the  Dentin. — Since  none  of 
the  obtundents  when  introduced  into  a  hypersensitive  cavity  or 
applied  to  hypersensitive  dentin  acts  with  sufficient  certainty  and 
without  danger  to  the  vitality  of  the  pulp,  we  have  conducted  experi- 


INDICATIONS  FOR  LOCAL  ANESTHESIA  123 

ments  to  ascertain  the  applicability  of  anesthesia  by  injection  for  this 
purpose.  These  experiments  with  novocain-suprarenin  solution  have 
yielded  such  splendid  results  in  regard  to  efficiency  and  innocuity 
that  the  injection  method  must  be  regarded  as  being  the  best  at  present 
for  dentinal  anesthesia.  If,  before  making  an  injection,  the  condition 
of  the  pulp  has  been  accurately  tested  by  thermal,  mechanical  or 
electric  stimulation,  we  can  carry  out  our  measures  without  harming 
the  metabolism  of  the  pulp,  and  can  often  fill  such  teeth  at  the  same 
sitting.  After  the  anesthesia  has  worn  off,  the  pulp  will  exhibit  a 
slightly  reduced  sensitivity,  but  will  soon  return  to  normal.  Accord- 
ing to  Euler's  and  Scheff's  experiments,  the  life  of  the  pulp  is  not 
imperilled,  provided  all  due  precautions  in  regard  to  solution,  tech- 
nique, and  instrumentarium  have  been  observed.  The  elimination 
of  the  excruciating  pain  which  usually  accompanies  any  attempt  at 
excavating  hypersensitive  dentin  is  indeed  a  blessing  to  highly  nervous 
patients. 

Injection  of  novocain-suprarenin  produces  also  anemia,  which  is 
evinced  by  the  pale  appearance  of  the  pulp  tissue.  Extreme  care  is 
therefore  required  in  the  preparation  of  a  cavity,  in  order  to  avoid  the 
danger  of  inserting  a  filling  too  close  to  or  directly  upon  an  exposed 
pulp  without  protecting  it  by  an  aseptic  pulp  capping,  or  of  overlooking 
the  initial  stages  of  an  already  established  pulpitis.  Such  mistakes 
are  apt  to  occur  because  all  the  usual  criteria  regarding  the  proximity 
of  the  condition  of  a  pulp  are  obliterated  by  the  anesthesia.  Death 
of  the  pulp  is  the  inevitable  consequence  of  such  errors  in  treatment. 
Cocain-adrenalin  mixtures  such  as  were  at  one  time  employed  for  the 
purpose  of  dentinal  anesthesia  often  caused  keen  disappointment, 
because  pulps  anesthetized  with  these  agents  preliminary  to  cavity  prep- 
aration would  subsequently  succumb  to  atrophy  or  necrosis.  These 
failures  were  justly  attributed  in  part  to  the  adrenalin,  the  dosage 
of  which  was  gradually  reduced.  Pure  cocain,  which  is  still  frequently 
used  for  obtunding  hypersensitive  dentin,  possesses  ischemic  properties 
which  are  so  intensified  by  the  addition  of  an  excessive  quantity  of 
an  adrenalin  preparation  that  the  anemia  of  the  injected  tissue  persists 
for  a  dangerously  long  period  of  time.     Unless  a  pulp  is  exceptionally 


124  INDICATIONS  FOR  LOCAL  ANESTHESIA 

strongly  constituted,  it  is  incapable  of  recovery,  and  doomed  to  morti- 
fication. On  the  other  hand,  the  doses  of  anesthetic  solution  advocated 
are  so  readily  absorbed  that  they  will  not  injure  a  normal  pulp. 

Quinin  as  a  Sedative  in  Cavity  Preparation. — In  highly  sensitive, 
hysterical,  or  neurasthenic  patients,  in  whom  anesthesia  is  contra- 
indicated,  it  is  of  advantage  before  dental  operations  to  give  internal 
doses  of  quinin  sulphate,  0.5  gram,  or  chloral  hydrate,  i  gram,  to 
quiet  the  nervous  system.  Le  Monnier,  of  Nizza,  who  is  said  to  have 
been  the  first  to  apply  quinin  in  dentistry,  reports  as  follows: 

"In  February  and  March  of  1887,  when  the  severe  earthquake 
took  place  in  Nizza,  I  had  occasion  to  observe  that  many  of  my  patients 
showed  so  much  nervousness  that  it  was  impossible  even  to  touch 
their  teeth,  and  all  the  measures  usually  resorted  to  in  such  cases 
failed.  Especially  teeth  in  the  advanced  stages  of  caries  were  so  sensi- 
tive that  they  could  not  be  excavated,  even  after  the  application  of 
caustics.  One  of  my  patients  was  seized  with  general  neuralgia  of 
the  head,  so  that  he  excused  himself  for  not  keeping  his  appointment. 
Several  hours  later  he  appeared,  however,  and  was  treated.  I  noticed 
that  he  did  not  make  the  usual  twitching  motions,  and  learned  that 
he  had  taken  a  large  dose  of  quinin  for  his  neuralgia. 

*'It  then  occurred  to  me  to  prescribe  for  another  similarly  nervous 
patient  0.5  gram  of  quinin  sulphate,  to  be  taken  for  two  successive 
days.  The  same  effect  as  in  the  former  case  was  observed,  and  the 
patient's  teeth  could  be  filled  during  the  next  sitting.  The  quinin 
seemed  to  reduce  the  sensitivity  of  the  teeth  much  more  effectively 
than  locally  applied  caustics. 

*'In  the  same  year  I  had  occasion  to  treat  a  woman  who  exhibited 
the  same  symptoms,  and  again  I  prescribed  0.5  gram  of  quinin  for 
two  successive  days.  I  was  agreeably  surprised  to  see  the  patient 
return  the  following  morning  and  submit  to  the  required  operation. 
These  experiences  have  recently  been  corroborated,  and  I  believe  to 
have  found  in  quinin  sulphate  a  valuable  addition  to  our  medicinal 
resources  in  nervous  cases." 

Chloral  Hydrate  as  a  Sedative. — Chloral  hydrate  (from  0.5  to  i 
gram)  also  is  a  sedative  which  obtunds  the  brain  function  and  reduces 


INDICATIONS  FOR  LOCAL  ANESTHESIA  125 

the  sensitivity  of  the  teeth.  In  speaking  of  this  drug,  Seitz  says: 
"In  1899  a  young  woman,  aged  eighteen  years,  who  was  undergoing 
nerve  treatment  in  a  sanatorium,  presented  for  dental  treatment. 
The  year  previous  she  had  met  with  an  accident  while  telephoning 
during  a  thunderstorm.  Lightning  struck  the  wire,  and  she  fell  sense- 
less beside  the  apparatus.  When  she  regained  consciousness,  several 
hours  afterward,  hyperesthesia  of  the  entire  surface  of  the  body  had 
set  in,  intolerable  pain  being  caused  upon  the  slightest  touch.  In  a 
year's  time  this  hyperesthesia  had  somewhat  abated  after  treatments 
of  various  sorts,  yet  it  persisted  in  the  trigeminal  region,  so  that  the 
mere  touching  of  the  teeth  with  a  finger  still  caused  great  pain,  and 
for  the  time  being  dental  treatment  could  not  be  instituted.  When, 
however,  idiopathic  odontalgia  set  in,  every  possible  therapeutic 
means  had  to  be  tried  to  give  relief,  and,  since  local  application  of 
chloral  hydrate  was  unfeasible,  the  internal  administration  of  this 
sedative  was  resorted  to.  The  patient  was  given  one  powder  of  1.5 
grams  in  wine  in  the  evening,  and  the  same  dose  on  the  following 
day,  half  an  hour  before  the  operation.  The  sensitivity  of  the  teeth 
was  actually  reduced  to  such  a  degree  that  even  the  dental  engine 
could  be  used.  During  the  operation  the  patient  was  in  a  seminarcotic 
condition  and  completely  indifferent,  and  showed  not  the  least  sign 
of  pain.  Half  an  hour  later  she  was  able  to  return  to  the  sanatorium 
by  carriage.     No  secondary  symptoms  occurred. 

"Similar  cases  have  been  reported  in  the  July,  1900,  issue  of  Dental 
Office  and  Laboratory.  According  to  this  report  chloral  hydrate  was 
administered  in  doses  of  from  10  to  15  grains,  which  acted  promptly 
even  in  cases  of  extreme  nervousness,  in  which  all  attempts  at  local 
anesthesia  of  the  dentin  had  failed.  Further  experiments  with  this 
sedative  are  therefore  highly  desirable." 

From  personal  experiments  with  chloral  hydrate  (i  gram)  and 
morphin  (o.oi  gram)  for  the  reduction  of  sensitivity,  we  have  come 
to  the  conclusion  that  internal  medication  of  this  nature  in  suitable 
cases  is  most  advantageous.  The  analgesic  effect  is  noted  after  from 
four  to  five  minutes,  characterized  by  a  notable  reduction  in  the  sen- 
sitivity   of    the    dentin,    varying    in    different    individuals.     In    highly 


126  INDICATIONS  FOR  LOCAL  ANESTHESIA 

excitable  persons  this  effect  is  frequently  noted  to  a  remarkably  exten- 
sive and  pronounced  degree.  While  harmless,  this  method  involves 
one  disadvantage,  inasmuch  as  the  certainty  of  its  success  is  not 
invariably  uniform.  Before  the  induction  of  either  general  or  local 
anesthesia,  however,  it  is  of  great  value  in  fortifying  the  psychic 
condition  of  nervous  patients. 

Pulp  Extirpation  and  Root  Canal  Treatment. — Healthy  pulps  can 
invariably  be  extirpated  painlessly  after  an  injection.  If,  for  some 
reason  or  other,  some  slight  sensitivity  in  a  pulp  is  encountered  after 
opening  into  the  pulp  chamber,  pressure  anesthesia  with  a  novocain- 
suprarenin  pluglet,  after  the  method  described,  will  quickly  abolish 
all  sensation.  The  immediate  filling  of  root  canals  is  indicated  only 
under  certain  rare  conditions.  In  pulpitis  due  to  pulp-stones  or  any 
other  cause,  injection  is  most  favorably  indicated  for  the  painless 
exposure  of  the  pulp,  the  coronal  portion  of  which  can  be  immediately 
amputated  with  a  sharp  spoon  excavator  of  suitable  size.  Immediate 
total  extirpation  and  root  canal  filling,  however,  is  contra-indicated  in 
such  cases,  where  the  arsenic  dressing  indicated  on  page  io6  invariably 
should  be  applied,  and  a  few  days  afterward  the  pulp  stumps  should 
be  removed,  the  root  canals  cleaned  and  disinfected,  and  a  root  canal 
filling  then  inserted. 

The  immediate  filling  of  root  canals  under  anesthesia  is  bad  prac- 
tice for  the  additional  reason  that  pulp  tissue,  unless  it  has  been 
coagulated  by  an  arsenic  dressing,  clings  very  tenaciously  to  the 
dentinal  walls  of  the  canal  and  cannot  be  removed  in  its  entirety. 
Even  the  pulps  in  incisors  and  canines  which  are  so  easy  to  extirpate 
are  frequently  torn  into  shreds,  the  complete  removal  of  which  is 
most  trying  and  uncertain,  not  to  mention  the  difficulties  involved 
in  extirpation  of  the  pulps  of  bicuspids  and  molars.  Moreover,  the 
hemorrhage  in  a  root  canal  is  very  difficult  to  arrest.  It  produces  an 
unsafe  edematous  zone  of  demarcation  at  the  apical  foramen  which  dis- 
appears only  gradually  after  subsequent  periodontitis,  and,  in  case  of 
infection  by  way  of  the  root  canal,  leads  to  suppurative  pericementitis 
which  renders  the  preservation  of  the  tooth  very  uncertain. 

Pulp   debris   that   has  not   been   removed    becomes    the   cause   of 


INDICATIONS  FOR  LOCAL  ANESTHESIA  127 

protracted  irritation  of  pulpitic  and  pericementitic  nature,  which  can 
be  combated  only  by  means  of  cauterization.  Even  granting  that 
there  are  many  teeth  which  remain  quiescent  under  such  conditions, 
it  is  a  well-known  fact  that  pain  in  pulps  may  be  of  greatly  varying 
intensity.  We  only  need  to  mention  the  cases  of  patients  who  present 
putrescent  pulps,  though  they  have  never  suffered  any  pain.  "Shot- 
gun methods"  of  pulp  and  root  canal  treatment  under  local  anesthesia 
must  be  absolutely  tabooed,  since  they  will  reflect  discredit  upon  a 
procedure  which  is  invaluable  if  judiciously  applied.  ''Quick  cure" 
artists,  of  course,  will  always  attribute  any  pain  following  their  slipshod 
treatments  to  "the  injection  or  the  toxicity  of  novocain." 

In  this  respect,  the  writer  fully  agrees  with  Schroder,  who  warns 
against  abandoning  devitalizing  fiber  in  favor  of  local  anesthesia. 
Rapid  pulp  and  root  canal  treatment  is  not  desirable,  and  local  anes- 
thesia should  be  employed  merely  to  allay  any  pain  arising  in  the 
course  of  treatment.  Local  anesthesia  is  a  welcome  accessory,  but 
not  a  substitute  for  arsenic. 

If,  in  exceptional  cases,  the  filling  of  root  canals  at  one  sitting 
becomes  necessary,  aqua  regia  seems  the  most  suitable  of  the  many 
drugs  recommended  for  the  destruction  of  pulp  remnants  and  the 
cleansing  of  canals.  A  number  of  cases  treated  in  this  manner  for 
the  sake  of  experiment  have  all  been  successful,  while  treatments  with 
antiformin,  formalin  solutions,  zinc  chlorid,  sodium  and  potassium, 
sulphuric  acid,  and  sodium  dioxid  were  followed  by  irritations. 

Crown  and  Bridge  Work. — In  crown  and  bridge  work  also,  local 
anesthesia  is  rapidly  gaining  ground.  Numerous  minor  operations, 
such  as  the  grinding  of  vital  teeth,  the  shaping  of  abutments,  the 
taking  of  measurements,  the  fitting  of  bands,  the  trying-in  and  setting 
of  crowns,  etc.,  are  so  painful  that  it  is  most  desirable  to  afford  relief 
to  the  patient.  The  mode  of  injection  of  novocain-suprarenin  solution 
for  this  purpose  is  the  same  as  described  in  this  book.  Occasionally, 
the  mucosa  and  gingival  tissue  can  be  successfully  anesthetized  by  the 
topical  application  of  a  20  or  30  per  cent,  novocain  solution;  alypin, 
however,  owing  to  its  more  rapid  and  penetrating  action,  is  preferable 
to  novocain. 


128  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Resume. — Novocain  solutions  of  a  concentration  up  to  1.5  per 
cent,  can  be  employed  with  impunity  in  arteriosclerosis,  diabetes, 
nephritis,  diseases  of  the  heart  and  lungs,  anemia,  chlorosis,  pregnancy, 
and  lactation.  Cocain  is  absolutely  contra-indicated  in  diseases  of 
the  heart  and  lungs. 

Novocain  injection  is  contra-indicated  in  ankylosis,  severe  purulent 
periostitis,  phlegmon,  obstinate  and  highly  excitable  patients,  neuras- 
thenics, and  hystericals. 

If  general  anesthesia  must  be  resorted  to,  analgesia  by  nitrous 
oxid  and  oxygen,  ethyl  chlorid,  ethyl  bromid,  or  ether  is  preferable  to 
deep  anesthesia. 

Among  the  local  anesthetics  available,  the  least  toxic  is  the  best. 
Novocain  is  from  seven  to  ten  times  less  toxic  than  cocain,  and  three 
times  less  toxic  than  other  substitutes  for  cocain.  It  is  not  a  habit- 
forming  drug  like  cocain. 

In  hypersensitive  patients  the  insertion  of  the  hypodermic  needle 
can  be  rendered  painless  by  topical  application  of  aconite,  phenol, 
or  a  30  per  cent,  novocain  or  alypin  solution. 

The  concentration  and  quantity  of  the  novocain-suprarenin  solu- 
tion advocated  for  dental  operations  is  far  below  the  toxic  limit. 

The  strength  of  the  solution  to  be  injected  must  be  gauged  by  the 
patient's  age  and  health. 

The  advantages  of  novocain-suprarenin  injection  may  be  summed 
up  in  Braun's  words:  "The  chief  advantage  of  local  anesthesia  con- 
sists in  the  possibility  of  introducing  almost  unlimited  quantities  of 
solution  into  the  body  and  obtaining  a  local  insensibility  of  heretofore 
unthought-of  intensity  and  duration.  This  possibility  has  opened 
the  field  of  surgery  to  local  anesthesia,  and  has  determined  its  remark- 
able progress  which,  even  with  an  improved  technique  of  injection, 
could  never  have  been  achieved  with  the  old  drugs.  The  introduction 
of  novocain  and  suprarenin  was  as  important  an  event  for  local 
anesthesia  as  that  of  cocain. 

Local  anesthesia,  therefore,  is  the  method  of  choice  whenever 
conditions  indicate  successful  desensitization  of  the  entire  field  of 
operation    by    moderate    doses    of    the    anesthetic    readily    applied; 


ANESTHESIA   IN  THE  THERAPY  OF  INFLAMMATION  129 

whenever  the  operator  is  famihar  with  the  technique  and  the  hmits  of 
this  method;  and  whenever  the  patient's  psychic  condition  does  not 
absolutely  demand  narcosis." 

ANESTHESIA    IN    THE    THERAPY    OF    INFLAMMATION. 

For  combating  inflammatory  conditions  in  the  oral  cavity  the 
writer,  as  early  as  1907,  recommended  the  generous  use  of  anesthesia, 
and  first  introduced  into  dentistry  a  method  which  had  already  proved 
most  effective  in  other  branches  of  medicine. 

"The  chief  object  of  anesthesia  in  the  therapy  of  inflammations 
is  to  bring  the  anesthetizing  agent  in  such  frequent  and  intimate  con- 
tact with  the  wound  that  pain  is  prevented  or  reduced  to  a  minimum." 
(Spiess.) 

The  patient's  sensation  corresponds  exactly  to  the  appearance  of 
the  wound  and  the  intensity  of  the  inflammation.  The  total  absence 
or  limited  degree  of  pain  permits  of  a  safe  conclusion  as  to  the  total 
absence  or  the  limited  extent  of  inflammation. 

Practical  Experiences  in  the  Oral  Cavity. — In  a  large  number  of 
throat  operations,  also  in  surgical  interventions  in  the  tongue,  the 
cheeks,  and  the  mucosa  of  the  lips,  anesthesia  has  been  therapeutically 
applied  by  Spiess  in  various  ways.  When  superficial  analgesia  proved 
insufficient,  submucous  injections  were  made  for  the  postoperative 
treatment  of  cases  in  which  anesthetic  dressings  were  technically 
impossible.  The  object  was  to  anesthetize  inflamed  tissue  and  wounds 
situated  in  such  areas,  and  to  keep  both  in  an  analgetic  condition  for 
a  prolonged  period  of  time. 

Tongue. — In  minor  injuries  of  the  tongue  due  to  awkward  biting 
or  to  sharp  edges  and  corners  of  carious  teeth,  and  in  the  intensely 
painful  desquamations  or  blisters  at  the  tongue  margin,  pain  rapidly 
disappears  after  several  applications  of  an  anesthetic  agent  made  at 
short  intervals. 

Coryza. — The  disagreeable  sensations  of  incipient  nasal  catarrh 
are  relieved  by  insufflation  of  orthoform  or  novocain  into  the  naso- 
pharyngeal cavity,   repeated   until   normal   sensation   is  reestablished. 


130  INDICATIONS  FOR  LOCAL  ANESTHESIA 

Coryza  can  be  aborted  with  absolute  certainty  in  this  way.  Insuffla- 
tion or  dressings  of  novocain  involve  no  risk  whatever,  since  novocain 
is  not  a  habit-forming  drug.  A  great  many  victims  to  the  cocain 
habit  have  been  started  in  their  fatal  practice  by  the  application  of 
cocain  to  their  nasal  mucous  membrane  by  thoughtless  physicians. 

Lacerations. — Minor  bruises,  lacerations,  also  wasp-  or  fly-stings, 
should  be  painted  with  orthoform  or  novocain  in  the  form  of  a  thick, 
watery  paste,  or  in  strong  solution,  until  all  pain  has  ceased.  Redness 
and  swelling  will  thus  be  arrested,  the  wound  edges  will  be  smoother, 
paler,  and  without  sensation,  and  the  wound  will  undergo  rapid  healing. 
By  all  these  observations,  extending  over  a  long  period  of  years,  it  has 
been  established  beyond  doubt  that  local  anesthetics  arrest  pain; 
that  wounds  when  dressed  with  one  of  these  agents  heal  without 
inflammation;  and  that  inflammation,  when  present,  subsides  in  a  very 
short  time. 

Modifying  the  Healing  Process. — It  has  also  been  found  that, 
together  with  pain,  redness  disappears.  Heretofore  it  was  impossible 
by  means  of  antiphlogistics  to  modify  an  inflammation  at  the  climax 
of  its  development  in  such  a  way  as  to  combat  redness.  With  the 
local  anesthetics  mentioned  this  can  be  accomplished  in  a  very  short 
time,  often  within  a  few  minutes;  moreover,  pain  can  be  absolutely 
abolished.  This  rapid  abatement  of  redness  can  be  explained  only 
by  assuming  a  direct  relationship  between  pain  and  redness,  in  oppo- 
sition to  Cohnheim's  theory.     It  simply  remains  to  establish: 

"i.  That  in  the  same  way  as  an  irritation  of  sensory  nerves  pro- 
duces hyperemia  by  way  of  reflex,  so  inhibition  of  this  irritation 
prevents  or  cures  hyperemia. 

"2.  That  therapeutic  treatment  should  be  directed  exclusively 
against  irritation  of  the  sensory  nerves,  and  that  the  normal  function 
of  bloodvessels  should  be  maintained. 

"3.  That  anesthesia  is  required  only  to  such  a  degree  as  to  inhibit 
reflex  action  and  to  prevent  in  the  parts  involved  any  changes  induced 
by  the  sensory  nerves  by  way  of  reflex." 

Examples  from  General  Pathology. — Insanity. — All  these  postu- 
lates are   fulfilled   in  anesthesias  occurring  in   the  hysterical  and   the 


ANESTHESIA   IN   THE  THERAPY  OF  INFLAMMATION  131 

insane.  Alienists  have  noted  many  cases  in  which  injuries,  burns, 
and  wounds  in  such  patients  healed  completely  without  any  reaction 
whatever.  Insane  patients  have  torn  open  the  abdominal  wound  after 
laparotomy,  touched  it  with  unclean  fingers,  yet  made  an  uneventful 
and  complete  recovery. 

Hysteria. — Hysterical  persons  can  stick  pins  in  their  skin  without 
any  untoward  consequences.  In  one  case  of  hysteria  the  patient,  who 
was  suffering  with  general  lack  of  sensitivity,  dipped  his  hands  repeat- 
edly in  boiling  water  without  being  scalded  in  the  least.  The  explana- 
tion may  be  that  the  afferent  nerves  being  insensible,  could  not  be 
stimulated,  and  the  reflexes  upon  the  vasomotor  nerves  remained 
inert.  Since  the  influence  of  the  heat  was  only  of  short  duration,  no 
direct  thermal  scalding  effect  was  produced  upon  the  tissues,  and 
no  hyperemia  or  inflammation  occurred. 

Experiments  with  spinal  anesthesia  in  animals  have  confirmed 
these  observations;  anesthetized  tissue,  upon  being  touched  with  a 
test-tube  filled  with  boiling  water,  exhibits  no  blisters  nor  even  redness. 

Local  Effects  of  Anesthesia. — The  sensory  sphere  is  paralyzed  not 
in  hysteria  only  but  also  in  those  pathological  conditions  in  which, 
besides  the  afferent  nerve  fibers,  the  sympathetic  nerves,  often  termed 
trophic  nerves,  are  affected.  Of  special  interest  to  us  are  the  cases  of 
gangrene  caused  by  drugs,  in  which  the  above  factors  probably  play  a 
part.  If  carbolic  acid  is  allowed  to  act  too  long  and  too  intensely, 
the  well-known  phenomena  of  thrombosis  appear,  and  not  only  the 
conductivity  of  the  afferent  fibers  is  inhibited  but  the  bloodvessels 
also  are  paralyzed,  and  their  function  is  destroyed.  Cold  of  sufficient 
intensity  also  will  abolish  sensation,  as  is  shown  by  the  ether  spray. 
If  its  influence  is  unduly  prolonged,  the  vasomotor  nerves  permeating 
the  vascular  walls  are  directly  affected  and  gangrene  ensues. 

While  anesthetization  of  the  afferent  nerves  promptly  prevents 
or  combats  inflammation,  all  inflammatory  phenomena  appear  more 
rapidly  and  severely  if  the  sympathetic  nerve  branches  are  paralyzed, 
as  Samuel  has  i)roved  by  animal  experimentation. 

Combating  Local  Irritability. — Pain,  which  is  a  specially  pronounced 
sjx'cihc    sensation     of    discomfort,     hence    a    condition     of    conscious 


132  INDICATIONS  FOR  LOCAL  ANESTHESIA 

sensation,  undoubtedly  intensifies  not  only  general  irritability  but  also 
local  irritability  and  actual  irritation  of  inflamed  areas  by  conscious 
and  wilful  acts;  furthermore,  by  way  of  unconscious  reflexes,  i.  e., 
by  way  of  the  centripetal  (afferent)  nerve  supply  of  the  irritated 
brain  centres.  This,  however,  is  after  all  not  the  primary  or  most 
important  cause  of  these  local  conditions.  It  is,  therefore,  the  first 
aim  of  the  therapeutist  to  reduce  the  increased  local  irritability — 
the  cause  of  the  abnormal  central  processes — either  directly  or  by  a 
general  reduction  of  the  normal  or  pathological  sensitivity  of  the 
nervous  system.  In  light  cases  this  may  be  accomplished  by  very 
simple  measures,  viz.,  by  covering  and  resting  the  inflamed  parts. 
Since,  however,  despite  the  protection  from  external  stimuli,  owing 
to  the  continually  recurrent  action  of  internal  tissue  stimuli,  local 
irritability  may  gradually  increase  and  become  excessive,  these  simple 
measures  are  frequently  inadequate,  and  an  attempt  must  be  made 
to  modify  the  local  irritability  of  the  tissues  themselves  by  the  appli- 
cation of  cold  or  heat,  which  reduces  the  disposition  to  abnormal 
irritability,  and  indirectly  regulates  the  blood-supply  and  the  process 
of  repair.  For  these  reasons,  Spiess'  method  is  especially  efficacious,  as 
it  acts  in  both  directions,  first,  by  the  thick  layer  of  orthoform  or 
novocain  powder  protecting  the  part  against  external  stimuli;  second, 
by  directly  preventing  the  irritability  of  the  morbid  tissue.  The 
latter  effect  is  produced  to  a  notable  degree  by  morphin  also,  which  is 
intended  to  act  not  as  an  hypnotic  but  merely  as  a  sedative;  for  it  is 
improbable  that  morphin  attacks  the  central  nervous  system  primarily. 
Such  direct  action  upon  the  nervous  centre  is  peculiar  to  chloroform 
and  ether,  while  morphin  affects  above  all  the  peripheral,  the  integu- 
mental  nerves,  and  reduces  the  irritability  of  the  central  nervous  system 
by  acting  from  the  periphery.  Simultaneously  with  the  altered  irri- 
tability of  the  tissue  the  healing  process  commences  its  favorable 
course,  not  because  pain  is  abolished  or  the  pain-conducting  nerves 
are  paralyzed,  but  because  the  source  of  pain  is  blocked  and  the 
cause  of  increased  irritability  is  removed,  so  that  the  nerves  are  na 
longer  abnormally  stimulated. 


ANESTHESIA   IN  THE  THERAPY  OF  INFLAMMATION  133 

Effect  of  Sedatives. — The  drugs  which  reduce  irritabihty  act  best 
in  the  early  stages  of  inflammation,  or  when  the  equilibrium  of  the 
tissues  is  tending  to  return  to  normal.  The  favorable  action  of  carbolic 
acid,  locally  applied,  must  be  attributed  chiefly  to  its  anesthetizing 
property,  and  it  appears  that  other  drugs,  the  favorable  action  of 
which  was  formerly  attributed  to  their  disinfectant  power,  possess 
the  same  sedative  elTect.  The  local  application  also  of  morphin  to 
inflamed  tissue  denuded  of  epithelium  exerts  a  favorable  influence, 
as  has  already  been  mentioned,  if  the  powder  is  allowed  to  dissolve 
on  the  mucosa,  or  if  a  few  drops  of  a  strong  solution  are  allowed  to 
be  absorbed. 

In  painful  lesions  of  the  mucous  membrane  of  the  mouth  and 
tongue  doses  of  potassium  sulphocyanate,  three  tablets  daily  after 
meals,  have  produced  remarkable  improvement  and  rapid  healing,  in 
my  practice,  so  that  it  seems  worth  while  to  collect  further  data 
regarding  sulphocyanate  treatment. 

Effects  of  Anesthesia. — ''No  inflammation  will  develop  if  the 
reflexes  conveyed  from  the  area  of  inflammation  by  way  of  the  afferent 
sensory  nerves  are  successfully  inhibited  by  anesthesia.  Rapid  healing 
of  inflammation  is  induced  by  anesthesia  of  the  centre  of  inflamma- 
tion, if  only  the  sensory  nerves  are  anesthetized,  and  the  normal 
function  of  the  sympathetic  (vasomotor)  nerves  is  not  interfered 
with"   (Spiess). 

At  all  events,  it  is  of  great  importance  to  prevent  external  irrita- 
tion, and,  if  this  is  no  longer  possible,  to  treat  the  area  favoring  internal 
irritation  in  such  a  way  as  to  reduce  the  hypersensitivity  of  the  tissues 
to  a  state  of  normal  sensitivity,  which  is  accomplished  by  anesthetics. 

Duration  of  Painlessness. — Process  of  Healing. — In  all  cases  which 
the  writer  has  had  occasion  to  observe,  painlessness  lasted  until  the 
termination  of  treatment.  In  prophylactically  treated  cases  no  inflam- 
mation of  extraction  wounds  set  in,  which  otherwise  would  surely 
have  occurred,  considering  the  severe  nature  of  the  operation.  It 
might  be  suggested  that  antiseptic  applications  alone  would  suffice 
to  bring  about  an  alleviation  of  pain  and  a  reduction  of  inflammation. 
Judging  from  experience,  however,  the  new  method  of  wound  therapy 


134  INDICATIONS  FOR  LOCAL  ANESTHESIA 

by  novocain  tamponade  marks  a  great  improvement  over  the  old  pro- 
cedures, inasmuch  as  no  postoperative  pain  arises,  and  the  healing 
process  is  rapid  and  uneventful  following  extractions  or  other  surgical 
operations. 

It  is  important  to  emphasize  that  local  anesthesia  is  as  valuable 
in  the  prophylaxis  as  in  the  curative  treatment  of  inflammation,  and 
this  relatively  novel  method  of  treating  inflamed  tissues  will  permit 
of  further  elaboration.  The  extensive  application  of  local  anesthesia 
will  bring  us  nearer  to  one  of  our  foremost  aims,  which  is,  to  make 
our  operations  as  well  as  postoperative  treatment  painless,  thereby 
hastening  the  process  of  repair  in  tissue  lesions. 


PART    III. 

TECHNIQUE  OF  LOCAL  ANESTHESIA. 


ANATOMICAL    STRUCTURE     OF    THE     OSSEOUS     FRAME     OF 

THE    MAXILLiE. 

The  osseous  frame  of  the  maxillae,  which  is  formed  by  the  maxilla 
and  the  mandible,  possesses  a  number  of  peculiarities  which  are  of 
special  importance  for  the  technique  of  local  anesthesia  and  the  diffu- 
sion of  injected  solutions.  The  pressure  exerted  in  injecting  serves 
to  force  the  anesthetic  through  the  canaliculi  in  the  outer  surface  of 
the  bone  into  the  interior  of  the  alveolus,  whereby  the  nerves  supplying 
the  teeth  can  be  paralyzed.  It  is  the  purpose  of  the  following  pages 
to  demonstrate  at  which  points  of  the  maxillary  apparatus  these 
areas  favorable  for  diffusion  are  constantly  found. 

The  Surfaces  of  the  Maxillae. — If  we  examine  the  jaws  of  a  macer- 
ated skull,  we  note  that  spongiose,  greatly  canaliculated  or  cancellated 
osseous  tissue  alternates  with  cortical  bone  which  presents  but  few 
canaliculi. 

Maxilla. — In  the  maxilla  the  compact  substance  extends  chiefly 
labially  and  buccally,  but  is  interrupted  in  most  skulls  by  definite  and 
invariably  present  cancellous  areas,  which  are  of  the  greatest  impor- 
tance in  local  anesthesia.  For  only  in  these  areas  is  it  possible  to 
force  the  solution  under  moderate  pressure  and  without  causing  lesions 
through  the  bone  into  the  alveolus,  and  to  infiltrate  and  anesthetize 
the  entire  profusely  innervated  environment  of    the    tooth  root   (see 

Fig.  46). 

Anterior  Surfaces  of  the  Maxillary  Bones. — In  Figs.  16  to 
22  the  anterior  views  of  several  skulls  of  persons  of  different  sex  and 


136 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


age  are  presented  in  order  to  show  the  various  stages  in  the  develop- 
ment of  the  sieve-Hke,  cancellous  or  spongiose  areas,  and  their  varying 
extent.  Red  arrows  indicate  specially  favorable  areas  which  guarantee 
a  good  diffusion  of  the  solution.     Fig.   i6  shows  the  skull  of  a  child, 


Fig.   i6 


Fig.   17 


Maxillae  of  child,  aged  seven,  showing  exten- 
sive cancellous  areas. 


Maxillse  of  young  man,  showing  extensive 
cancellous  areas. 


Fig.   18 


Fig.  19 


Maxillae  of  young  person,  showing  extensive 
cancellous  areas. 


Maxillae  of  old  person,  showing  few 
perforations. 


aged  seven  years,  in  which  the  conditions  are  extremely  favorable 
for  diffusion;  Fig.  17,  the  skull  of  a  man,  aged  twenty  years,  in  which 
the  characteristic  cancellous  areas  plainly  appear. 

In  the  maxilla  as  well  as  in  the  mandible  the  alveolar  ridges  at  the 


ANATOMICAL  STRUCTURE  OF  OSSEOUS  FRAME  OF  MAXILLM     137 


necks  of  the  teeth  always  exhibit  sieve-Hke  perforations,  as  does  the 
depression  at  the  anterior  nasal  spine,  or  incisive  fossa  in  the  region 
of  the  root  apices  of  the  upper  central  incisors.  In  the  mandible  the 
cancellous  areas  are  limited  to  the  anterior  portion  in  the  region  of 


Fig.  20 


Fig.  21 


Maxilla;  of  old  person,  showing  few  perforations.  Maxilla  of  adult,  showing  numerous  perforations. 

Fig.  22  Fig.  23 


Maxilla;  of  adult,  showing  numerous  perforations. 


Lateral  view  of  Fig.   16. 


the  chin,  or  mental  region  (see  Figs.  17  and  22).  Mesially  to  the  root 
apex  of  the  canine,  in  the  mental  fossa,  on  either  side,  groups  of  small 
foramina  are  distributed  which  sometimes  extend  up  to  the  alveolar 
ridge  (see  Figs.  16,  18,  21,  and  22).     Especially  Fig.  22  shows  plainly  how 


138 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


finely  perforated  the  mental  portion  may  be.  The  skulls  of  older  persons, 
especially  in  the  mandibular  portions,  show  very  few  perforations 
(see  Figs.  19  and  20). 


Fig.  24 


Fig.  25 


Lateral  view  of  Fig.  17. 
Fig.  26 


Lateral  view  of  Fig.  li 
Fig.  27 


Lateral  view  of  Fig.  19. 


Lateral  view  of  Fig.  20. 


The  lateral  aspect  of  the  same  skulls  shows  that  in  the  maxilla,  in 
the  molar  region,  the  cancellous  areas  become  fewer,  while  in  the  man- 
dible they  are  lacking  entirely  (see  Figs.  23  to  29).  In  the  mandible 
the  alveolar  ridge  only  is  perforated,  while  toward  the  base  a  thick  cor- 
tical layer  prevails.  The  youthful  jaw  (see  Fig.  23)  exhibits  the  widest 
extent  of  cancellous  bone;  even  the  mandible  in  this  skull  is  traversed 
by  numerous  canaliculi.     Fig.  24  gives  a  good  view  of  the  cancellous 


ANATOMICAL  STRUCTURE  OF  OSSEOUS  FRAME  OF  MAXILLA     139 

fossa  at  the  level  of  the  root  of  the  upper  canine;  this  canine  fossa  in  all 
skulls   is  of  more  or   less   canaliculated   structure.      The   middle   root 


Fig.  28 


Fig.  29 


Lateral  view  of  Fig.  21. 


Lateral  view  of  Fig.  22. 


Fig.  30 


Extent  of  cancellous  bony  tissue  at  the  maxillary  tuberosity.    Above  the  empty  alveolus  of  the  third 
molar  large  foramina  are  seen  by  which  the  posterior  superior  dental  nerves  enter  the  maxilla. 

portion  in  these  teeth,  however,  is  often  covered  by  a  dense  cortical 
layer  (see  Figs.  25  to  27). 


140 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


The  character  of  the  osseous  tissue  above  the  upper  bicuspids  is 
of  great  interest.  It  is  especially  closely  perforated,  generally  to  the 
entire  extent  from  the  alveolar  ridge  to  the  root  apex  (see  Figs.  24 
and  25). 


Fig.  31 

Incisive  or  anterior 
Incisive  suture     palatine  canal 


31edian  palatine 
suture 


Minor  palatine 
foramina 


Palatine  spines 


Posterior  palatine 
foramen 


Transverse  palatine  /  Posterior  nasal  spine 

suture  Portion  of  horizontal  plate 

of  palate  bone 

View  of  palatal  surface  of  maxilla. 

The  upper  molars  are  covered  by  an  osseous  plate  of  chiefly  cortical 
character,  which  above  the  third  molars  usually  is  again  densely 
perforated,  as  a  glance  at  the  tuberosity  in  Fig.  30  plainly  shows. 

Foramina  in  the  Anterior  Surface. — The  anterior  surfaces 
of  the  maxillae  present  two  very  important  large  foramina  which 
permit  the  passage  of  important  nerves  and  vessels,  namely,  in  the 
maxilla  the  infra-orbital  foramen  above  the  root  of  the  first  bicuspid, 


ANATOMICAL  STRUCTURE  OF  OSSEOUS  FRAME  OF  MAXILLA     141 

in  the  mandible  the  mental  foramen  below  and  between  the  first  and 
second  bicuspids. 

The    Posterior    Surfaces    of    the    Maxillary    Bones. — Maxilla. — 

Palatal  Surface  of  the  Maxilla. — The  posterior  surface  of  the  maxilla 


Fig.  32 


Fig.  33 


Palatal  surface  of  maxilla  of  youthful  person, 
showing  extensive  cancellous  areas. 

Fig.  34 


Palatal  surface  of  maxilla  of  youthful  person, 
showing  extensive  cancellous  areas. 

Fig.  35 


Palatal  surface  of  maxilla  of  adult,  showing 
few  perforations. 


Palatal  surface  of  maxilla  of  old  person,  showing 
few  perforations. 


is  traversed  by  numerous  canals  which  are  distributed  very  regularly. 
Fig.  31  shows  the  palatal  view  of  the  maxilla.  The  hard  palate  in  its 
anterior  and  median  portions  is  seen  to  be  closely  perforated.  At 
the  bicuspids  the  canaliculi  in  the  alveolar  bone  decrease  in  number 


142 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


at  the  middle  portion  of  the  roots,  and  gradually  disappear  toward  the 
molars.     In  this  region  we  find  the  large  posterior  palatine  foramen. 

These  conditions  are  clearly  shown  in  Figs.  32  to  35.  These  illus- 
trations furthermore  disclose  the  fact  that  the  cancellous  areas  in  the 
palatal  surface  vary  in  different  individuals.  Figs.  32  and  33  represent 
densely  perforated  youthful  skulls;  Figs.  34  and  35  the  considerably 
less  cancellated  maxillae  of  older  subjects. 


Fig.  36 


Fig.  37 


Inner  surface  of  mandible,  showing  dense  bone. 


Foramina  are  noted  at  the  symphysis. 


Foramina  in  the  Palatal  Surface. — In  the  palatal  surface  of  the 
maxilla  we  find  two  well-marked  large  foramina,  the  incisive  or  anterior 
palatine  foramen  behind  the  central  incisors  and  the  posterior  palatine 
foramina  at  the  level  of  the  third  molars,  as  clearly  illustrated  in  Fig. 
31.     (See  also  Figs.  32  to  35.) 

Mandible. — Inner  Surface  of  the  Mandible. — The  inner  surface 
of  the  mandible,  in  contradistinction  to  the  maxilla,  is  entirely  non- 
canaliculated.  Only  at  the  internal  genial  tubercles,  or  mental  spines, 
some  partly  fair-sized  foramina  are  noted  which  frequently  reach  to 
the  alveolar  ridge,  and  in  transverse  sections  are  seen  to  communicate 
with  the  mandibular  canal  (see  Fig.  38;  also  Figs.  36  and  37),  while  the 
entire  posterior  portion  up  to  the  third  molars  is  almost  impenetrable 
and  non-canalicular  (see  Fig.  39).  Above  the  angle  of  the  jaw,  how- 
ever, in  the  ascending  ramus  we  find  a  very  large  aperture,  namely. 


THE  MANDIBULAR  OR  INFERIOR  DENTAL  FORAMEN  143 

the  mandibular  or  inferior  dental  foramen  (see  Figs.  39  to  41),  which 
is  important  for  conductive  anesthesia  of  the  mandible. 

Fig.  38 


Section  through  symphysis  of  mandible.     Some  of  the  foramina  on  the  inner  surface  communicate 
with  the  inferior  dental  canal,  fibers  of  the  lingual  nerve  probably  joining  the  inferior  dental  nerve. 

THE    MANDIBULAR   SULCUS    AND    THE   MANDIBULAR    OR 
INFERIOR  DENTAL  FORAMEN. 

In  adults  the  ascending  ramus  begins  a  little  behind  the  third 
molar,  sometimes  in  an  abruptly  ascending  surface.  At  its  basis, 
when  regarded  as  resting  upon  the  alveolar  process,  the  ascending 
ramus,  in  front  view,  shows  an  outer  buccal  anterior  ridge,  represent- 
ing the  last  ascending  portion  of  the  external  oblique  line  (see  Figs. 
39  to  43).  About  0.5  cm.  inward  and  backward  of  this  line  runs  a 
ridge  bordering  the  lingual  surface,  the  internal  oblique  line,  which 
gradually  loses  itself  in  the  posterior  section  of  the  coronoid  process. 
Between  these  two  lines  in  the  bony  surface  is  situated  a  more  or  less 
pronounced  deep  groove  which  we  might  call  the  retromolar  fossa 
(see  Figs.  40,  42,  and  43).  This  fossa,  which  is  covered  by  a  thin 
layer  of  mucous  membrane,  serves  as  the  most  reliable  place  of  orien- 
tation for  the  palpating  finger  before  inducing  conductive  anesthesia 
of  the  mandible. 

About  the  middle  of  the  internal  surface  of  the  ascending  ramus 
the  large  mandibular  or  inferior  dental  foramen  is  situated  (see  Figs. 
39  to  41,  and  43),   which   marks  the  starting-point  of    the  mylohyoid 


144 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


groove  which  runs  obhquely  downward  and  anteriorly  (see  Figs.  39,  41, 
and  43).  The  orifice  of  the  foramen  itself  is  protected  anteriorly  by 
a  spiculum  of  bone  of  varying  size,  the  mandibular  lingula  (see  Figs. 
39,  41,  and  43).  This  lingula  may  be  developed  as  a  pointed  plate 
of  bone  or  as  a  tongue-like  cover,  or  only  as  a  thickened  process  on 
the  anterior  margin  (see  Fig.  41).  Sometimes  the  lingula  is  connected 
with  the  lower  free  margin  of  the  orifice  of  the  mandibular  canal  by  a 
small  bony  spiculum  or  bridge. 


Fig.  39 


Sigmoid  notch 

Pterygoid  depression 
\  Condyloid  process 


Angle 
Mylo-hyoid  groove 
'<  Siibmaxilhiry 
'     fossa 
Mylo-hyoid 
Internal  genial        ridge 
tubercles 

Side  view  of  inner  surface  of  right  half  of  mandible.  The  red  arrow  indicates  the  direction  in 
which  the  needles  should  be  pushed  forward  over  the  lingula.  The  red  circle  indicates  the  area 
of'  injection. 

In  adults  the  mandibular  foramen  is  always  situated  above  the 
alveolar  ridge  and  in  a  horizontal  plane  about  1.5  cm.  from  the  anterior 
ridge  of  the  jaw,  the  external  oblique  line  (see  Figs.  41  and  43).  The 
two  halves  of  the  mandible,  when  viewed  from  front,  gradually  diverge 
toward  the  angle,  so  that  the  inner  surface  of  the  ramus  with  the  man- 
dibular foramen  is  inclined  posteriorly  and  pharyngeally,  and  appears 
entirely  covered  by  the  internal  oblique  line  (see  Figs.  41  and  42). 

The  mandibular  foramen  is  continued  posteriorly  and  upward  by  a 


THE  MANDIBULAR  OR  INFERIOR  DENTAL  FORAMEN 


145 


shallow  groove  of  varying  depth  and  extent,  which  Spee  and  others 
have  named  the  mandibular  sulcus  (see  Figs.  39  to  43).    By  its  anatomic 

Fig.  40 


Condyloid  process-  — 

Mandibular  sulcus -1 

lor  dental 
foramen 


-f-  «  Coronoid  p  races 


Internal  oMique 
line 

Exieriial  oblique 
line 

Internal  oblique 
line 


Mental  foramen 


Relationship  of  the  ascending  ramus  to  the  body  of  the  jaw.    The  red  arrow  indicates  the  direction 
in  which  the  needle  should  be  advanced  to  the  inferior  dental  foramen. 

nature  this  sulcus  is  the  most  favorable  place  for  the  reception  of  the 
solution    injected    in    conductive    anesthesia    of    the    mandible.      The 

10 


146 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Fig.  41 
Coronoid  process-^^  /^,    Lhiqula 

■S   / 


_-^f—  Condyloid  jjrocess 


"'^aKfe.T, 


Inferior  dental 

foramen 


X. Annie 


'^'^Sfefo-; 


Coronoid  process r- 


— Condyloid  process 


. Inferior  dental 

foramen 


Condyloid 
process 


Lingula 


Inferior  dental 
foramen 


—Angle 

ingle 
J  Mylo-hyoid  groove 

»  Submaxillary  fossa 

Mylo-hyoid  ridge 

Variations  of  the  mandibular  or  inferior  dental  foramen  at  different  ages:  A,  mandible  of  a  child, 

aged  seven  years  (the  needle  should  be  inclined  slightly  downward).    B,  mandible  of  a  youth,  aged 

eighteen  years.    C,  mandible  of  a  male  adult,  aged  thirty  years.    The  red  arrows  indicate  the  direction 

of  the  needle. 


THE  MANDIBULAR  OR  INFERIOR  DENTAL  FORAMEN  147 

needle  is  therefore  inserted  a  little  above  the  lingula,  and  the  solution 
is  deposited  in  this  sulcus  (see  Figs.  42  and  43). 

Fig.  42 


Front  view  of  position  of  syringe  in  mandibular  anesthesia:   i,  internal  oblique  line;  2,   external 
oblique  line;  3.  insertion  of  needle  about  i  cm.  above  masticating  surfaces  of  molars. 


Fig.  43 


Posterior  view  of  position  of  needle  in  mandibular  anesthesia:  i,  external  oblique  line;  2  internal 
obhque  line;  3,  position  of  needle  at  superior  margin  of  lingula;  4,  most  suitable  length  of  needle 
behind  lingula  fa  further  advancement  would  result  in  failure);  6,  position  of  needle,  i  cm  above 
level  of  masticating  surfaces  of  molars;  7,  lingula;  8,  inferior  dental  foramen. 


148  TECHNIQUE  OF  LOCAL  ANESTHESIA 

The  topography  of  this  mandibular  sulcus  and  the  anatomic  con- 
ditions which  are  important  in  mandibular  anesthesia  will  be  discussed 
in  detail  in  the  special  chapter  on  Conductive  Anesthesia  (see  page  202). 


THE    MINUTE    STRUCTURE    OF    THE   ALVEOLAR   PROCESS. 

Structure  of  the   Osseous  Substance. — In  ground  sections  of  the 
alveolar  processes  of  either  jaw  two  different  layers  of  osseous  tissue 


Extent  of  spongiose  or  cancellous  bone  within  an  exposed  alveolus. 

are  continually  found,  namely,  the  sparingly  canaliculated  substance, 
the  compact  substance,  and  the  highly  cancellated  and  medullated 
tissue,  the  spongiose  substance.     The  former  in  the  mandible  shows  a 


EXPLANATION    OF   ABBREVIATIONS    IN    FIG.    45. 

%B,  lower  left  second  bicuspid;  iB,  lower  left  first  bicuspid;  iC,  lower  left  canine;  2/,  lower  left 
lateral  incisor;  1/,  lower  left  central  incisor;  /i,  lower  right  central  incisor;  li,  lower  right  lateral 
incisor;  d,  lower  right  canine;  M.  F.,  mental  foramen;  Cm.,  mandibular  canal;  F.  C,  facial  cortical 
layer;  L.  L.,  lingual  cortical  layer;  pal.  Cort.,  palatal  cortical  layer;  E.  S.,  extraction  scar;  C,  upper 
right  canine;  P,  upper  right  lateral  incisor;  /',  upper  right  central  incisor;  B^,  upper  right  second 
bicuspid;  Spong.,  spongiose  (cancellous)  bone;  Cort.,  cortical  layer;  M2,  lower  right  second  molar; 
Mz,  lower  right  third  molar;  B^,  upper  right  first  bicuspid;  M"^,  upper  right  second  molar;  M^,  upper 
right  third  molar;  M'^,  upper  right  first  molar;  Cort.  pal.,  palatal  cortical  layer;  Tuber,  max.,  maxillary 
tuberosity. 


Fig.  45 


10    C.  tn:Cort.Cor't.  Cm.    H      12     Cort.  C   ... 


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pal.  Cort.—  :.^       .  :,        -^Alveolar  margin 


pal.  Cort. 


>-F.  C. 
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3 


pal. 
O  Cort.  E.  S. 


C 


19 


[  jj^".^*  /'  "     Alveolus  Alveolar  margin 

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20        Spong, 


Nasal  wall 


F.  C.       9 

Horizontal  and  vertical  sections  of  the  alveolar  process  in  the  maxilla  and  mandible. 


150  TECHNIQUE  OF  LOCAL  ANESTHESIA 

solidly  arranged  periphery,  its  thickness  varying  with  age  and  with 
the  long  diameter  of  the  bone.  The  spongiose  substance  which 
occupies  the  interior  of  this  solid  cortical  capsule  resembles  a  sponge 
in  the  arrangement  of  the  individual  lamellae  and  rods.  These  osseous 
rods  are  generally  so  arranged  in  regard  to  direction  as  to  radiate 
from  the  cortical  layer  (see  Fig.  45,  Nos.   i  to  20). 

Toldt  attributes  this  architecture  of  bone  partly  to  an  intracarti- 
laginous  ossification,  partly  to  the  normal  developmental  processes 
(apposition  and  resorption)  of  the  surrounding  compact  layer.  With 
advancing  age  the  spongiose  medullated  spaces  increase,  while  the 
osseous  supports  of  the  teeth  decrease,  so  that  the  compact  substance 
gradually  closes  in  upon  a  space  of  little  internal  resistance. 

Structure  of  th^  Alveoli. — The  deiital  alveolus  may  be  regarded  as 
a  crater-shaped  depression  in  the  spongiose  substance  consisting  of 
highly  porous  osseous  tissue,  in  which  the  root  is  contained  (see  Fig. 
45,  No.  19;  Fig.  48,  Nos.  17  and  19).  The  individual  alveoli  are 
separated  by  septa,  consisting  of  thin  and  porous  lamellae  from  two 
approximating  alveoli  and  of  spongiose  tissue  developed  between  the 
latter  (see  Figs.  45,  46,  and  48).  The  alveoli  of  the  upper  bicuspids, 
especially  the  first,  also  those  of  the  lower  bicuspids  in  their  fundus, 
contain  ridge-like  eminences,  septal  processes,  which  fit  into  the  longi- 
tudinal depressions  in  the  roots  of  these  teeth.  The  alveolar  walls 
always  exhibit  fine,  cribriform,  sieve-like  perforations,  which  increase 
in  number  and  diameter  toward  the  upper  margin  (see  Figs.  45,  46, 
and  48). 

These  perforations,  which  are  always  present  in  varying  number 
in  the  alveolar  ridge,  and  seem  to  permit  of  rapid  diffusion  of  the 
anesthetic  solution,  have  heretofore  been  unduly  neglected;  they  are 
the  fundamental  feature  upon  which  the  technique  of  infiltration  or 
mucous  anesthesia  is  based. 

Transverse  Sections  of  the  Jaws. — Fig.  45,  Nos.  i  to  20,  shows  a 
number  of  instructive  bone  sections  in  which  the  various  relations 
of  dental  roots  to  their  alveoli,  and  the  structure  of  the  jaws  themselves, 
can  be  studied.  Nos.  i  to  5  illustrate  lamellar  portions  of  the  anterior 
section  of  the  mandible  from  the  left  second  bicuspid  to  the  right  canine. 


THE  MINUTE  STRUCTURE  OF  THE  ALVEOLAR  PROCESS         Vol 

Besides  the  instructive  transverse  sections  of  roots,  we  can  trace 
m  No.  2  the  gradually  increasing  thickness  of  the  outer  and  inner 
cortical  layers,  and  study  the  manner  in  which,  between  these,  the 
spongiose  layers  are  arranged  around  the  bodies  of  the  roots.  In  No. 
4  only  the  apical  portions  of  the  long  roots  of  the  canines  can  be  seen, 
while  in  No.  5  the  widely  cancellated  tissue  appears  in  the  proximity 
of  the  mandibular  canal,  which,  on  the  left,  communicates  through 
the  exposed  mental  foramen  with  the  anterior  surface.  While  most 
roots  are  surrounded  with  spongiose  substance,  the  roots  of  the  canines 
are  gripped  by  the  cortical  layer,  which  in  this  region  bulges  remark- 
ably; this  condition  contributes  largely  to  the  firmness  of  the  support- 
ing abutments  of  the  normal  denture,  namely,  the  canines. 


Fig.  46 


Zygomatic  process^ 
Infra-orbital  foramen  ^""^"^ 


Alveolar  septa  ^^ 


Palatal  surface     Compact  hone 
Posterior  palatine  foramen 

View  of  cancellous  alveolar  margin  of  maxilla.    The  alveolar  septa  and  margins  are  densely 

cancellated. 


The  same  condition  is  plainly  shown  in  Fig.  45,  No.  7,  which,  like 
Nos.  8,  9,  15,  and  16,  illustrates  additionally  the  organization  of  an 
old  extraction  wound  into  spongiose  substance  (see  Nos.  8  and  9, 
between  C^  and  B^,  Nos.  15  and  16,  between  B^  and  MO-  Nos.  14  to 
18  present  the  structural  details  of  one  maxillary  half,  showing  that 
the  cortical  layers  are  here  of  a  considerably  more  delicate  develop- 
ment than  in  the  mandible.  The  palatine  cortical  layer  also  is  seen 
to  be  canaliculated.     In   No.    19  it  is  further  seen   that  the  cortical 


Fig. 


47 


Vertical  sections  through  the  alveolar  process  of  the  maxilla.    Left  side,  the  facial  surface;  right  side, 
the  lingual  surface;  i  to  4,  incisors;  5  and  6,  canine;  7  to  10,  bicuspids;  11  to  16,  molars. 


Fig.  48 


Vertical  sections  through  the  alveolar  process  of  the  mandible.  Left  side,  the  lingual  surface; 
right  side,  the  facial  surface:  i  to  4,  incisors  and  canines;  5  to  9,  bicuspids;  10  to  16,  molars;  17 
to  21,  alveoli  of  molars  from  another  skull. 


154 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


layers  covering  the  posterior  buccal  and  palatal  surfaces  of  the  maxilla 
may  increase  or  decrease  in  thickness.  While  the  buccal  surface 
starting  from  the  alveolar  margin  often  increases  from  a  delicate 
stratum  to  a  thick  cortical  layer,  the  palatal  covering  is  rather  thick 
at  the  alveolar  margin,  whence  it  gradually  tapers.  Fig.  44  shows  the 
open  alveoli  of  an  upper  first  molar;  this  illustration  again  emphasizes 
the  fact  that  the  most  favorable  conditions  for  diffusion  exist  at  the 
alveolar  margin. 

^  Fig.  49 


"^A 


/ 


Bloodvessels  (blue)  and  lymph  vessels  (red)  in  spongiose  substance  of  maxillae. 

Sections  of  the  Maxilla  and  Mandible. — In  order  still  further  to 
elucidate  the  conditions  for  diffusion  in  the  maxillary  bones,  we  have 
made  special  vertical  sections  of  the  maxilla  and  the  mandible,  as 
shown  in  Figs.  47  and  48. 

Maxilla. — In  Fig.  47,  Nos.  i  to  16,  the  relations  of  the  upper 
teeth  to  the  alveolar  process  are  illustrated.  The  left  side  of  each 
of  these  sections  represents  the  facial;  the  right,  the  palatal  surface. 


THE  MINUTE  STRUCTURE  OF  THE  ALVEOLAR  PROCESS 


155 


Nos.  I  to  6  show  the  anterior  teeth  including  the  canine;  Nos.  7  to  10, 
the  bicuspids;  Nos.  11  to  16,  the  molars.  All  these  illustrations  pre- 
sent on  the  palatal  surface  a  broad  osseous  layer,  which,  on  the  facial 
surface,  is  delicate  and  lamellar  for  the  greater  part,  and,  up  to  the 

Fig.  50 


I   ^^. 


\- 


Diffusion  of  injected  staining  solution  (red)  within  the  bony  alveolar  process.    (Animal  experiment.) 

bicuspids  is  specially  thin  in  the  proximity  of  the  root  apices,  which 
area  is  generally  richly  cancellated.  It  is  here,  therefore,  that  the 
best  possible  diffusion  can  be  obtained.  The  roots  of  the  molars  fre- 
quently are  covered  with  but  a  thin  lamella,  which  is,  however,  almost 


156 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


non-canaliculated,  and  increases  in  thickness  in  the  third  molar  region. 
This  tooth,  by  way  of  compensation,  is  surrounded  at  its  root  apices 
by  richly  cancellated  bone,  so  that  it  can  be  perfectly  well  anesthetized 
by  inserting  the  needle  high  up  on  the  gum. 

Fig.  51 


Appearance  of  red  stain  particles  within  the  pulp  capillaries  (vessels  blue). 

Mandible. — Sections  through  the  mandible  plainly  show  the  massive 
nature  of  the  cortical  layer  on  either  side  (see  Fig.  48).  While  in  the 
anterior  teeth  the  facial  surface  of  the  bone  (on  the  right  in  the  illus- 
trations) is  of  relatively  thin  structure,  its  thickness  increases  con- 
siderably from  the  bicuspids  on,  and  at  the  molars  (Nos.  10  to  16) 
attains  the  same  proportions  as  the  lingual  surface.  Though  in  the 
mandible  local  anesthesia  by  infiltration  is  of  little  value,  it  can  be 
effected  by  injection  at  the  cervical  margin  of  the  gum,  because  the 
alveolar  ridges  in   all   lower  teeth   are  of  spongiose  character.     This 


THE  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS        157 

fine,  spongiose,  cancellous  area  in  the  alveoli,  even  in  the  molars,  is 
limited,  however,  to  the  upper  marginal  portion,  as  illustrated  in 
Fig.  48,  Nos.  17  to  21,  also  in  Fig.  45. 

The  foregoing  renders  it  sufficiently  apparent  that  the  technique 
of  injection  depends  not  only  upon  the  nerve  supply  of  the  masticatory 
apparatus  but  also  to  a  great  extent  upon  the  character  of  the  bony 
substance.  We  shall  have  occasion  to  prove  that  the  technique  of 
local  anesthesia  as  demonstrated  subsequently  is  based  on  these  ana- 
tomical principles,  and  for  that  very  reason  guarantees  such  a  high 
degree  of  perfection  and  safety. 

Details  of  Diffusion. — In  order  to  establish  the  velocity  and  manner 
of  diffusion  of  solutions  injected  in  the  jaws,  the  writer  has  injected 
the  periosteum  of  the  maxilla  and  the  mandible  in  various  animals, 
such  as  cats,  with  isotonic  coloring  solutions,  using  the  same  tech- 
nique as  for  local  anesthesia.  In  all  cases  the  cancellated  bone  was 
permeated,  and,  where  cortical  substance  was  present,  the  red  carmine 
solution  penetrated  by  way  of  the  foramina  (see  Fig.  49).  Spongiose 
cancellous  bone  tissue  absorbs  the  stain  with  uniform  avidity,  per- 
mitting it  to  penetrate  into  the  medullary  spaces  (see  Fig.  50).  In 
most  cases  the  interior  of  the  jaw  was  entirely  permeated  with  the 
colored  solution  in  five  minutes,  the  pulp  within  from  six  to  eight 
minutes.  The  capillaries  of  the  pulp  at  the  odontoblastic  layer  are 
seen  to  be  filled  with  particles  of  stain  (see  Fig.  51),  while  within  the 
osseous  canaliculi  red-stained  lymph  vessels  are  found  chiefly  in  peri- 
vascular arrangement  (see  Fig.  49).  This  seems  conclusive  proof 
that  an  isotonic  solution,  such  as  the  novocain-suprarenin  solution 
advocated,  reaches  the  interior  of  the  alveolar  process  in  a  short  time. 
Its  diffusion  is  most  rapid  and  extensive  in  spongiose  substance,  while 
in  cortical  areas  it  proceeds  only  by  way  of  the  few  and  generally  large 
foramina. 

THE  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS. 

The  sensibility  of  the  masticatory  apparatus  is  controlled  by  the 
fifth  cranial  nerve,  the  trigeminal. 


158  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Roots  of  the  Trigeminal  Nerve. — The  trigeminal  nerve  arises  by  a 
ventral,  smaller,  motor  root,  and  a  dorsal,  larger,  sensory  root  at  the 
pons  Varolii,  and  extends  anteriorly  to  the  apex  of  the  petrous  portion 
of  the  temporal  bone  (see  Fig.  52).  Here  the  sensory  root  forms  the 
large  semilunar  or  Gasserian  ganglion,  from  which  proceed  the  three 
main  branches,  the  ophthalmic,  the  maxillary,  and  the  mandibular 
(see  Fig.  53).  The  motor  root  passes  independently  beneath  the  ganglion 
to  the  third  division,  which,  being  a  mixed  nerve  consisting  of  sensory 
and  motor  fibers,  is  distinguished  from  the  exclusively  sensory  first  and 
second  divisions. 

Branches  of  Distribution  of  the  Trigeminal  Nerve. — The  Ophthal- 
mic Nerve. — The  first  or  ophthalmic  division  of  the  trigeminus  passes 
from  the  Gasserian  ganglion  through  the  superior  orbital  or  sphenoidal 
fissure  to  the  orhit.  It  is  divided  into  three  branches,  lacrimal,  frontal, 
and  nasal.  The  lacrimal  nerve  passes  forward  along  the  lateral  wall  of 
the  orbit  at  the  upper  border  of  the  external  rectus  muscle,  and  supplies 
the  lacrimal  gland,  the  distal  corner  of  the  eye,  and  the  conjunctiva. 
The  frontal  nerve  runs  forward  under  the  roof  of  the  orbit,  and  gives 
off  two  branches,  the  siipr a- orbital  nerve,  and  the  supratrochlear  nerve. 
The  nasal  nerve  gives  off  a  long  branch  to  the  ciliary  ganglion,  also 
the  long  ciliary  nerves  to  the  posterior  portion  of  the  sclera.  It  then 
continues  to  the  median  wall  of  the  orbit,  giving  off  the  posterior 
ethmoidal  nerve  to  the  posterior  ethmoidal  cells,  and  the  infratrochlear 
nerve  to  the  mesial  angle  of  the  eye,  supplying  the  integument  of  the 
eyelids,  and  the  lacrimal  sac.  The  ciliary  ganglion,  which  also  belongs 
to  the  first  division  of  the  trigeminus,  is  situated  in  the  posterior  third 
of  the  orbit  laterally  of  the  optic  nerve  (second  cranial  nerve),  and 
has  three  roots,  one  short  inotor  root,  one  long  sensory  root,  and  one 
sympathetic  root  (see  Fig.  52). 

The  Maxillary  Nerve. — The  second  or  maxillary  division  of  the 
trigeminus  passes  from  the  Gasserian  ganglion  through  the  foramen 
rotundum  to  the  sphenomaxillary  fossa,  and  thence  becomes  the 
infra-orbital  nerve.  Its  branches  are  orbital  or  temporomalar  branch, 
infra-orbital,  with  the  posterior,  middle,  and  anterior  superior  dental 
branches,  and  the  sphenopalatine  branch  (see  Figs.  52,  53,  55,  and  56). 


160  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Close  to  the  sphenopalatine  foramen  lies  the  sphenopalatine  or 
Meckel's  ganglion,  consisting  of  sensory  (the  sphenopalatine  branches), 
motor,  and  sympathetic  roots  (the  Vidian  nerve).  From  the  ganglion 
the  sensory  nasal  branches  pass  to  the  nasal  cavity,  one  branch,  the 
nasopalatine  nerve,  running  to  the  anterior  palatine  canal.  The  pala- 
tine nerves  pass  through  the  pterygopalatine  canal  to  the  oral  cavity, 
where  they  break  up  into  the  anterior,  middle,  and  posterior  palatine 
nerves.  They  supply  the  mucous  membrane  of  the  palate  with  sensory, 
and  the  muscles  of  the  soft  palate,  excepting  the  tensor  palati  muscle, 
with  motor  filaments  (see  Figs.  52,  54,  and  56). 

Branches  of  Distribution  of  the  Maxillary  Nerve. — The  maxillary 
nerve  passes  through  the  infra-orbital  sulcus  and  canal  to  the  infra- 
orbital region  of  the  facial  surface  of  the  maxilla,  giving  off  numerous 
branches  in  its  course  (see  Figs.  52,  55,  and  56).  In  passing  through 
the  infra-orbital  canal  it  gives  off  the  superior  dental  branches  at 
various  intervals  through  the  minute  canals  in  the  body  of  the  maxilla 
(see  Figs,  52,  53,  and  56).  These  middle  and  a?tterior  superior  dental 
branches  supply  the  alveolar  process,  sending  off  small  twigs  to  the 
teeth.  Before  entering  the  canal,  the  maxillary  nerve  gives  off  the 
posterior  superior  dental  nerves  to  the  maxillary  tuberosity,  which  partly 
follow  the  arteries,  partly  pass  through  their  own  foramina  into  the 
tuberosity  (Figs.  52,  55,  and  56)  and  the  body  of  the  maxilla.  Follow- 
ing the  arteries,  they  pass  forward  above  the  molars,  branching  out 
within  the  facial  wall  of  the  maxilla,  and  finally  communicate  with 
the  middle  and  anterior  superior  dejital  nerves.  They  supply  the  oral 
mucosa,  the  molars,  the  mucous  membrane  of  the  maxillary  sinus, 
the  periosteum,  and  the  pericementum  (see  Figs.  55  and  56). 

The  terminal  portion  of  the  maxillary  nerve,  or  infra-orbital  branch, 
frequently  divides  into  from  two  to  four  branches  which  arise  closely 
together  from  the  infra-orbital  foramen  (see  Fig.  55).  They  run  in  a 
curve  from  behind  and  above  downward  to  forward  and  inward. 
Their  numerous  subdivisions  form  a  thick  nerve  plexus,  which  in 
turn  sends  off  finer  branches  to  the  oral  mucosa,  the  floor  of  the 
nasal  cavity,  the  incisors  and  canines,  and  the  spongiose  substance 
(see  Fig.  55). 


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162  TECHNIQUE  OF  LOCAL  ANESTHESIA 

The  Mandibular  Nerve. — The  third  or  mandibular  division  of  the 
trigeminus  makes  its  exit  from  the  skull  through  the  foramen  ovale, 
dividing  into  a  superior,  chiefly  motor  root,  and  an  inferior,  chiefly 
sensory  root.  Through  the  foramen  spinosum  the  mandibular  nerve 
gives  ofif  the  recurrent  or  meningeal  branch  to  the  dura  mater  (see 

Fig.  53)- 

From  the  superior  motor  root  the  masticatory  muscles  are  supplied 
by  the  following  branches:  The  masseteric,  the  internal  and  external 
pterygoid,  and  the  deep  temporal  branches.  The  buccinator  nerve  is  the 
only  sensory  branch,  and  supplies  the  mucous  membrane  of  the  cheek. 

From  the  inferior  root,  the  inferior  dental,  the  lingual,  and  the 
auriculotemporal  branches  are  given  off  (see  Figs.  53  and  54). 

The  inferior  dental  nerve,  before  passing  into  the  mandibular  or 
inferior  dental  canal,  gives  off  a  motor  branch,  the  mylohyoid  nerve, 
and  through  the  mental  foramen  a  sensory  branch,  the  mental  nerve 
(see  Figs.  53,  54,  and  57). 

The  lingual  nerve  supplies  the  tongue  and  the  floor  of  the  oral 
cavity  with  sensory  filaments  (see  Fig.  58).  From  the  chorda  tympani 
nerve,  which  is  a  branch  of  the  facial  nerve  (the  seventh  cranial),  it 
receives  secretory  filaments  which  it  conveys  to  the  large  mandibular 
glands.  The  chorda  tympani  nerve  receives  fibers  from  the  glosso- 
pharyngeal nerve  (the  ninth),  by  anastomosis  of  the  facial  with  the 
glossopharyngeal  nerve. 

To  the  third  division  of  the  trigeminus  belongs  also  the  otic  ganglion 
(see  Fig.  53),  which  is  situated  immediately  below  the  foramen  ovale. 
The  small  superficial  petrosal  nerve,  a  continuation  of  the  tympanic 
plexus,  conveys  secretory  and  sympathetic  filaments  to  the  ganglion. 
The  secretory  filaments  come  from  the  glossopharyngeal,  the  sym- 
pathetic ones  from  the  sympathetic  plexus  of  the  internal  carotid 
artery,  whence,  through  the  caroticotympanic  branches,  they  com- 
municate in  the  tympanic  cavity  with  the  small  superficial  petrosal 
nerve. 

The  motor  root  of  the  ganglion  is  derived  from  the  trigeminus 
through  filaments  from  the  internal  pterygoid  nerve. 

The  otic  ganglion  also  sends  motor  filaments  to  the  tensor  palati 


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THE  MANDIBULAR  NERVE 


163 


and    the   tensor   tympani   muscles,    secretory    filaments    to    the   parotid 
gland. 

The  main  trunk  of  the  third  division  of  the  trigeminal  is  the  man- 
dibular or  inferior  dental  nerve.  After  giving  off  the  mylohyoid  branch 
it  enters  the  long  mandibular  or  inferior  dental  canal  (see  Figs.  54  and 
57),  passing  along  with  the  artery  and  the  venous  plexus  below  the  roots 
of  the  molars  (see  Figs.  53  and  54).  Before  its  entrance  into  the  canal 
it  gives  off  a  few  delicate  twigs  to  the  oral  mucosa  and  the  periosteum; 


Fig.  55 

Zygomatico-femporal  branch 

Orbital  {teiuporo- malar)  branch 
Lacrimal  N. 

Superior  maxillary  N. 

Semilunar  ganglion 


Aiiastomoi 
with 
tal 
Zygomatico-^ 
cial  (malar, 
branch 
Anterior  termi- 
nal  branches 
of  infra-orbi- 
tal N. 


Facial  N. 
Great  superficial 
■^ —     petrosal  N. 
Deep  petrosal  N. 


Buccal  branch  of/ucial  N. 


;  ;      Vidian  N. 
Jl^^Spheno-palaiine  ganglion 
Posterior  superior  dental 
branches 


Distribution  of  superior  maxillary  nerve.  (Hirschfeld  and  Leveille.)  The  outer  wall  of  the  left 
orbit  is  removed,  also  most  of  the  soft  tissues  in  the  vicinity  of  the  maxilla.  (From  Rauber  and 
Kopsch.) 


within  the  canal  it  is  frequently  subdivided  into  several  parallel 
branches.  One  of  these  extends  as  far  as  the  central  incisors,  where 
it  anastomoses  with  the  nerves  of  the  other  side.  At  the  mental  fora- 
men it  gives  off  the  mental  branch  which  supplies  the  anterior  labial 
surface  of  the  mandible,  the  mucosa,  and  the  lower  lip  (see  Fig.  53). 
In  its  course  the  inferior  dental  nerve,  in  close  relationship  to  the 
corresponding  vessels,  gives  off  two  large  separate  branches,  a  posterior 
branch  to  the  molars,  and  a  middle  branch  between  the  mandibular 
and  the  mental  foramina  to  the  bicuspids. 


164 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


In  front  of  the  inferior  dental  nerve  (see  Figs.  53  and  54),  the  Imgual 
nerve  passes  to  the  tongue,  sending  off  on  its  way  a  side  branch  which 
is  minutely  broken  up  in  the  anterior  portion  of  the  mandible  (see 
Fig-  57).  In  the  bicuspid  region  it  ascends,  finely  distributing  itself 
in  the  periosteum  as  far  as  the  genial  tubercles. 

Fig.  57 


Temporal  M. 

External  ptery- 
goid M. 

Facial  N. 

Internal  ptery- 
goid M. 

Lingual  N. 

Buccinator  N. 
Buccinator  M. 

Inferior 
dental  N. 

Mandible 


Sternomaftoid  M. 


Inferior  dental  or  mandibular  nerve.    The  strata  of  bone  covering  the  nerve  have  been  removed. 
(Original  specimen  by  Gasser,  of  Marburg  Anatomical  Institute.) 


Anastomoses. — Biinte  and  Moral  have  emphasized,  m.ore  strongly 
than  this  has  been  done  before,  the  anastomoses  within  the  trigeminal 
area,  which  are  of  greatest  importance  in  dentistry.  These  inves- 
tigators use  the  fitting  term  "nerve  loops"  for  the  intercommunication 
of  some  of  the  branches  of  the  trigeminal  nerve,  the  most  important 
of  which   are  the  following:  anterior  palatine  nerve  (second  division) 


jV  otmjviipido 
■^  Minqipiivji 

•S[  msoipd  d?9(j 
100 J,  L3iimu,s 


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s-S       rt 


snx9id  pita  wo  ivuM^uj 
•jf  mvdubfi}  dOiu^x 

■^  pysoxpd  imojfMdns  nmug-^ 

■uhl  omvdm.fi')  pwo  ivso^pd       _    . 

^t7!f.i9dns  7V3.iti  ud3m-3q  sisow,ojsvuv  ' 

"AT  2oso.ipd  imoif-iddns  imif)  _  ,  _  -  X 

•u^  oiuvdmfi)  -\-" 

vuvim'Muddmdqspowopmiv  "  ,.V--'- 

uoijBunS  9mnoiu90     '     yi'- 

BMqsf^Ai.  /"  sinpdniMm  maMM     '     , 


'AT  'l'>l-^.'{ 


C   o 


t-.      CD 

O    03 
•I    C 


THE  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS       165 

communicates  in  the  anterior  palatine  canal  with  the  nasopalatine 
nerve  (second  division)  (see  Figs.  53  and  54).  On  the  anterior  surface 
of  the  mandible  the  posterior,  middle,  and  anterior  superior  dental 
nerves  anastomose  with  one  another  and  with  the  infra-orbital  nerve 

Fig.  58 


Submaxillary 
fossa         /' 


Sublingual 
gland 


I  Lingual  N. 
i  Inferior 
\    dental  N. 


1  Mylohyoid  N. 


Tongue 


Lingual  nerve.     (Original  specimen  by  Gasser,  of  the  Marburg  Anatomical  Institute.) 

(see  Figs.  52  and  56),  as  do  the  infra-orbital  nerves  in  the  median 
line  at  the  nasal  spine.  In  the  mandible,  the  inferior  dental  nerves 
of  each  side  communicate  with  one  another  at  the  symphysis.  Nu- 
merous terminal  loops  of  the  second  and  third  divisions,  which  supply 


166 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


the  alveolar  processes,  are  distributed  in  the  oral  mucosa  as  the 
gingival  posterior  and  anterior  superior  nerves,  and  the  large  and  small 
palatine  nerves. 


Fig.  59 


Spheno-pala- 
tine  gang- 
lion 


^ w^  4  T'ermwiaJ  branch 
"      .of    naso-pala- 
tine  N. 


•Anastomosis  of 
palatine  N. 


Lingual  iV. 


Anastomosis  of  nasopalatine  and  anterior  palatine  nerves.     Distribution  of  lingual  nerve  in  the 

mandible.     (After  Biinte  and  Moral.) 

Stimuli  Referred  by  Anastomoses. — The  nerves  supplying  the 
individual  teeth  are  really  nerve  terminals  which  communicate  with 
the  central  nervous  system  by  larger  tracts  of  supply.  Since  they 
stand  also  in  direct  relationship  to  neighboring  areas,  it  is  easily 
understood  why  pathological  conditions  in  teeth  very  frequently 
involve  neighboring  normal  pulps.  It  is  not  surprising,  then,  that 
especially  in  dental  disorders  the  pain  is  so  extraordinarily  intense, 
frequently  affecting  large  neighboring  areas.  By  anastomoses  with 
the  opposite  side,  sensations  are  often  referred  thereto.  Owing  to  the 
relations  of  the  trigeminal  nerve  to  the  facial  nerve,  pain  in  diseases 
of  the  lower  teeth  is  often  referred  to  the  ear  by  way  of  the  tympanic 
branch,  as  the  mandibular  nerve  communicates  through  the  auricula- 


AREAS  OF  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS     167 

temporal  nerve  with  the  nerves  of  the  external  auditory  meatus,  whence 
the  tympanic  branch  passes  to  the  tympanic  membrane.  In  the 
maxilla  we  frequently  observe  radiation  of  pain  from  the  alveolar 
process  to  the  temporal  region,  the  eyes,  the  forehead,  the  neck,  or 
even  the  upper  arm.     The  same  relationships  are  noted  in  anesthesia. 

Strong  electric  currents  applied  to  the  teeth  or  the  oral  mucosa 
disclose  certain  very  interesting  relationships  between  the  different 
areas  of  nerve  supply  in  the  facial  portion  of  the  skull.  Oscillations 
in  the  eye  and  an  increase  in  the  lacrimal  secretion,  for  instance,  can  be 
produced  by  applying  strong  electric  currents  to  all  the  teeth,  both  upper 
and  lower;  that  is,  by  stimulation  of  the  second  and  third  divisions 
of  the  trigeminal  nerve.  Stimulation  of  the  soft  palate  is  usually 
followed  by  an  increase  in  lacrimal  secretion  only.  These  relation- 
ships are  of  the  greatest  importance  in  regard  to  pathology,  as  serious 
disorders  of  the  teeth  may  involve  the  organs  supplied  by  the  second 
trigeminal  branch. 

The  diagram  in  Fig.  53  clearly  illustrates  the  intimate  relations 
existing  between  the  trigeminal  nerve  and  the  branches  of  other 
cranial  nerves  within  its  area  of  distribution. 


AREAS  OF  NERVE  SUPPLY  OF  THE  MASTICATORY 

APPARATUS. 

In  order  to  offer  a  clear  picture  of  the  distribution  of  the  individual 
nerve  trunks  in  the  masticatory  apparatus,  a  thorough  knowledge  of 
which  is  of  paramount  importance  in  local  anesthesia,  the  different 
areas  of  nerve  supply  are  represented  in  colored  diagrams  (see  Figs. 
60  to  64).  In  the  head  we  distinguish  generally  three  definite  areas, 
supplied  by  the  three  divisions  of  the  trigeminal  nerve,  as  illustrated 
in  Fig.  60. 

Maxilla. — Looking  at  the  anterior  surface  of  the  skull,  we  note 
in  the  maxilla  three  such  areas  (see  Fig.  61).  The  upper  incisors  and 
canines  belong  to  the  blue  area  supplied  by  the  anterior  superior  dental 
nerves;  the  molars  to  the  yellow  area  supplied  by  the  posterior  superior 


Fig.  6o 


I-. 


II  —  - 


III_ :^ 


Superficial  area  of^ 
distriimtioH     of 
cervical  plexus 


Superficial  area  of 
distribution  of 
])Osterior  hrancJi 
of  cervical  Nn. 


Vertico-auricnlo- 
mental  line 


Distribution  of  trigeminal  nerve.    I,  II,  III  divisions  of  trigeminal  nerve.     (After  Toldt.) 

Fig.  6i 


Infra-orbital 
'     foramen 

Infra-orbi- 
tal N. 

Ant.  super,  den- 
■     tal  Nn. 
Middle   super. 
,     dental  Nn. 
Fast,  super,  den- 
tal Nn. 


Buccinator  N.t_} 


-4-  'i  Buccinator  N. 


.  Inferior  dental  N. 


'  Mental  N. 


Areas  of  nerve  supply  of  maxillary  apparatus.  Front  view.  Red  area:  inferior  dental  nerve. 
Yellow  area:  posterior  superior  dental  nerves.  Green  area:  Middle  superior  dental  nerves.  Blue 
area:   anterior  superior  dental  nerves. 


AREAS  OF  NERVE  SUPPLY  OF  THE  MASTICATORY  APPARATUS     169 

dental  nerves,  while  the  bicuspids,  in  the  green  area,  stand  in  relation- 
ship to  both  sides,  being  supplied  by  the  anterior  and  middle  superior 
dental  nerves.  The  blue  and  yellow  areas,  therefore,  represent  portions 
that  are  supplied  by  one  single  nerve  branch  each,  while  the  green 

Fig.  62 


Infra-orbital  N. 
Zygomatic  process 

Ant.  super,  dental  Nn., 


Post,  super,  den- 
tal Nn. 


Post,  super,  den- 
tal Nn. 


^      _  Molars 

Incisors  and  picuspidA 
canines  \ 

Middle  super,  dental  Nn. 

Areas  of  nerve  supply  of  maxilla.  Blue  area:  anterior  superior  dental  nerves  (incisor  and  canine 
region).  Green  area:  middle  superior  dental  nerves  (bicuspid  region).  Yellow  area:  posterior 
superior  dental  nerves  (molar  region). 


areas  are  of  mixed  character.  The  nerve  supply  of  the  latter  areas 
is  furnished  by  three  branches,  viz.:  the  middle  superior  dental  nerve 
proper  which  supplies  the  bicuspids,  and  the  anterior  and  posterior 
superior  dental  nerves  on  either  side  which  anastomose  with  the  middle 


170 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


branch  (see  Fig.  52).  In  the  green  and  blue  areas,  the  nerves  run 
partly  behind  the  facial  plate  of  the  alveolar  process,  partly  below 
the  mucous  membrane  of  the  maxillary  sinus  (see  Figs.  52  and  56).  In 
some  portions,  this  plate,  as  we  have  seen,  is  of  spongiose  character, 
and  renders  it  most  favorable  for  the  diffusion  of  anesthetic  solu- 
tions. At  the  maxillary  tuberosity  several  branches  of  the  posterior 
superior  dental  nerves  penetrate  the  facial  wall  (see  Figs.  52,  55,  and 
56).  These  nerve  branches  can  be  reached  by  the  hypodermic  needle 
and  anesthetized  by  injection  at  the  tuberosity. 

Fig    63 

Naso-palatine  N. 


Anastomosis  (•eliveen 
anterior  palatine 
and  naso-palatine''^-  i'-' 

Nn. 


Anterior  pal 
atine  N. 


Areas  of  nerve  supply  of  palatal  surface  of  maxilla.    Blue  area:  naso-palatine  nerve.    Red  area: 
anterior  palatine  nerve  (molar  region). 


The  palatal  surface  of  the  maxilla  may  be  divided  into  an  anterior 
blue  and  a  posterior  red  section.  The  latter  is  supplied  by  the  anterior 
palatine  nerve  (see  Fig.  63)  which  emerges  upon  the  hard  palate  by 
the  posterior  palatine  foramen  above  the  third  molar  (see  Figs.  54 
and  55),  and,  passing  forward  and  toward  the  median  line,  communi- 
cates in  front  with  the  nasopalatine  nerve  (see  Fig.  54).     The  filaments 


Fig.  64 


Naso-palative  N... 


Incisive  foramen 
Area  supplied   by  ■ 
naso-pcdatine  N. 


Hard  palate 


Molar  region 


Anterior  region 

Areas  of  nerve  supply  of  palatal  surface  of  maxilla.  Red  area:  anterior  palatine  nerve  (molar 
region).  Blue  area:  naso-palatine  nerve  (incisor  and  canine  region).  The  bicuspid  region  is 
supplied  by  both  branches. 

Fig.  65 


Area  partly  Hupplied  by  hucdnator  N. 

Areas  of  nerve  supply  of  anterior  portion  of  mandible.  Red  area:  inferior  dental  nerve.  From  the 
mental  foramen  emerges  the  mental  nerve.  The  mucous  membrane  in  the  molar  and  bicuspid 
region  fyellow)  is  partly  supplied  l;y  sensory  fibers  of  the  buccinator  nerve. 


172 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


of  the  latter  supply  the  area  at  the  anterior  teeth  as  far  as  the  bicuspids 
which,  as  in  the  mandible,  receive  their  supply  from  both  branches. 
Viewed  laterally,  these  two  nerve  branches  are  distributed  over  the 
area  just  described  (see  Fig.  54). 


Fig.  66 


Incisors  and 
canine 


Area  supplied 
by   inferior,.... 
dental   and 
lingual  Nn. 


Mandibular.. 
canal 


Inferior  den- 
tal N. 
•*,.,Lingual  N. 
(filue) 


/  i 

Area  supplied  Lingual  N.  Mylo-hyoid  N. 
hy   inferior 
dental  N. 

Areas  of  nerve  supply  of  lingual  portion  of  mandible.    Red  area:  inferior  dental  nerve.    The  mylo- 
hyoid nerve  branches  off  at  the  inferior  dental  foramen.    Blue  area:  lingual  nerve. 


Mandible. — The  nerve  supply  of  the  mandible  is  dominated  entirely 
by  the  mandibular,  or  inferior  dental  nerve,  which  passes  through  the 
mandibular  canal  (see  Fig.  53).  The  red  area,  which  marks  its  dis- 
tribution, is  interrupted  only  in  its  posterior  or  molar  portion  by  an 
orange-yellow  area  indicating  sensory  fibers  of  the  buccinator  nerve, 
which  supplies  the  buccal  mucosa  of  the  molars  and  bicuspids  (see 
Figs.  65  and  66).  Before  entering  the  canal,  the  mandibular  nerve 
also  gives  off  some  delicate  sensory  filaments  to  the  mandibular  mucosa 
(see  Fig..  57). 

The  lingual  surface  of  the  mandible  is  supplied  jointly  by  the 
inferior  dental  nerve  and  one  of  its  coordinate  branches,  the  lingual 


DISTRIBUTION  OF  NERVES  IN  THE  ALVEOLAR  PROCESS  AND  PULP     173 

nerve.  The  latter  is  a  large  branch  placed  in  front  and  mesially  of  the 
inferior  dental  nerve,  and  ascends  in  the  region  of  the  first  bicuspid 
to  the  alveolar  process  as  far  as  the  incisors,  where  it  is  minutely  dis- 
tributed in  the  periosteum  (see  Fig.  58).  Some  of  its  terminal  filaments 
in  the  vicinity  of  the  genial  tubercles  probably  extend  through 
foramina  to  the  anterior  portion  of  the  mandibular  canal  (see  Fig. 
38).  Shortly  before  entering  the  inferior  dental  foramen,  the  inferior 
dental  nerve  gives  off  a  motor  branch,  the  mylohyoid  nerve  (see  Figs. 
53,  54,  and  66). 


THE  MINUTE  DISTRIBUTION  OF  NERVES  IN  THE  ALVEOLAR 
PROCESS,  PERIOSTEUM,  AND  PULP. 

Periosteum. — Within  the  alveolar  processes  the  nerve  trunks  are 
distributed  most  minutely.  The  periosteum  as  well  as  the  pericementum 
are  especially  richly  endowed  with  sensory  filaments.  Fig.  67  repre- 
sents Vater's  or  Pacini's  corpuscles,  sensory  end  organs  which  are 
always  present  in  the  periosteum. 

Pulp. — The  nerves  of  the  pulp  are  sensory  fibers  of  the  trigeminal 
nerve  and  enter  the  pulp  in  one  or  more  stout  bundles  or  trunks  by 
the  apical  foramen  together  with  the  bloodvessels.  About  the  middle 
portion  of  the  pulp  canal  these  trunks  branch  out  considerably,  so 
that  in  incisors,  for  instance,  from  thirty  to  forty  bundles  can  be 
counted.  These  bundles  consist  of  cylindrical  strands  composed  of 
medullated  nerve  fibrils  of  from  6  to  10  microns  in  diameter  (see  Fig. 
70).  Each  bundle  is  surrounded  by  a  sheath  of  connective  tissue 
resembling  the  perineurium.  The  fibrils  in  these  bundles  run  in  the 
direction  of  the  long  axis  of  the  tooth,  and  can  clearly  be  traced  to  the 
internal  terminal  lamina  of  the  dentin  (see  Fig.  69). 

Sensitivity  of  the  Dentin. — From  the  above  it  follows  that  the 
odontoblastic  layer  represents  the  most  important  tissue  area  of  the 
pulp,  as  well  as  of  the  entire  tooth.  In  this  area  the  most  delicate 
tendrils  of  the  nerve  filaments  are  distributed,  arborizing  with  a 
graceful  network  of   lymphatic  capillaries,    around    the   odontoblasts, 


174 


TECHNIQUE  OF  LOCAL  ANESTHESIA 

Fig.  67 


Nerves  in  the  periosteum  and  interosseous  ligament  in  the  forearm  with  Pacinian  corpuscles,  i , 
radius;  2,  ulna;  3,  interosseous  membrane;  4,  tendon  of  biceps  brachii  M.;  5,  tendon  of  brachialis 
M.;  6,  supinator  M.;  7,  pronator  quadratus  M.;  8,  median  N.;  9,  interosseous  antibrachii  volaris  N., 
10,  branches  of  flexor  profundus  digitorum  M.;  11,  periosteal  branch  to  ulna;  12,  nerve  to  flexor 
poUicis  longus  M.;  13,  radial  N.;  14,  trunk  of  interosseous  Nn.;  15,  second  branch  of  radial  N.;  16, 
periosteal  branch  to  radial  N.;  17,  branch  of  interosseous  Nn. ;  18,  communicating  branch  from 
interosseous  antibrachii  volaris  N.;  19,  20,  21,  branches  of  interosseous  Nn.;  22,  ulnar  N.;  23,  24, 
branches  of  interosseous  Nn.;  25,  26,  27,  branches  of  interosseous  volaris  N.;  28,  interosseous  anti- 
brachii posterior  N.     (From  Rauber  and  Kopsch.) 


Fig.  68 


H 


/ 


oL       6^/ 


/     \ 


JV.  A. 


Od,. 


Nerves  and  bloodvessels  in  the  pulp.      X  56.     D,  dentin;  Od,  odontoblasts;  G ,  bloodvessels; 
iV,  nerves;  A,  ramusculi  ot  nerve  fibers. 

Fig.  69 


^■;:z:^^ 


>»      \\ 


Nerve  fibers  running  bclwccn  the  odonlublasts  to  the  dentin.     (Fritsch.) 


176  TECHNIQUE  OF  LOCAL  ANESTHESIA 

in  the  same  manner  as  the  bloodvessels  of  the  pulp  break  up  into 
innumerable  capillary  loops.  As  the  odontoblasts  with  their 
cell  processes  control  the  nutrition  and  the  sensitivity  of  the  dentin 
which  forms  the  bulk  of  the  tooth,  their  relationship  to  the  nervous 
and  lymphatic  systems  is  easily  understood.  Since,  on  the  other  hand, 
Tomes'  fibrils  are  undoubtedly  of  a  protoplasmic  character,  and  nerve 
tendrils  can  be   traced  only   to   the  internal   terminal  lamina  of  the 

Fig.  70 


-•  7';;- 

/ 

/ 

'  ^ 

r. 

/ 

Od. 

Horizontal  section  of  odontoblasts  and  nerve  fibrils  arborizing  around  them.    X 1 560.    t/,  odontoblasts 
surrounded  by  nerve  fibrils;  NF,  nerve  fibrils;  P,  protoplasm;  K,  nucleus;  Oi,  odontoblasts. 

dentin,  all  stimuli  in  the  dentin  are,  perhaps,  transmitted  by  way  of 
the  protoplasm,  whence  they  are  conveyed  to  the  sensory  end  organs 
in  the  odontoblastic  cell-layer. 

According  to  the  recent  investigations  of  Dependorf,  Fritsch,  and 
others,  the  presence  of  nerve  fibrils  in  the  dentinal  tubuli  is  highly 
probable;  this,  of  course,  would  mean  a  direct  conduction  of  sensations 
in  the  dentin. 


DISTRIBUTION  OF  NERVES  IN  THE  ALVEOLAR  PROCESS  AND  PULP     177 

Nerve   Supply  of  the   Walls   of  the  Bloodvessels  in  the  Pulp.— A 

few  words  should  be  said  regarding  the  nerve  supply  of  the  bloodvessels 
and  captllanes.  The  bloodvessels  are  supplied  by  motor  as  well  as 
sensory  plexuses,  most  of  the  latter  belonging  to  the  great  sympathetic 
system.  Their  fibers  are  non-medullated  and  terminate  generally 
within  the  adventitious  coat  (tunica  adventitia)  and  the  tunica  media 


Fig.  71 


Nerves  of  capillaries.     (After  Joris.)     (From  Rauber  and  Kopsch.) 


in  a  sensory  end  plate.     The  capillaries  are  enmeshed  in  a  reticulum 
of   delicate   neurofibrillae,    as   illustrated   in    Fig.    71.      These   fibrillse 
when  acted   upon  by  suprarenin,  bring  about  the  contraction  of  the 
vascular  walls  and   for  some  time  maintain  the  vascular  constriction 
which  IS  so  desirable  during  local  anesthesia. 


12 


178  TECHNIQUE  OF  LOCAL  ANESTHESIA 

THE    TECHNIQUE    OF   INJECTION. 

After  the  foregoing  considerations,  the  technique  of  injection  is 
merely  a  question  of  logical  utilization  of  the  factors  described.  The 
peculiarities  of  the  bony  structures,  as  well  as  the  nerve  supply,  furnish 
us  with  definite  guiding  lines  for  a  well-defined  procedure  of  injection. 
Although  some  modifications  have  been  suggested,  the  methods 
described  in  this  book  furnish,  so  far,  the  most  reliable  basis  for  suc- 
cessful and  safe  operations. 

Anesthesia  by  local  injection,  as  formerly  employed  in  dental 
practice,  was  limited  to  anesthesia  of  the  mucous  membrane.  In  recent 
years  conductive  anesthesia  was  introduced,  and  with  the  adoption 
of  this  method  in  dentistry  our  results  have  become  truly  phenomenal. 
Conductive  anesthesia  in  the  mandible,  for  example,  is  really  the 
first  and  only  method  to  guarantee  complete  and  safe  anesthesia  of 
that  region.  For  it  is  undeniable  that  anesthesia  of  lower  molars  by 
the  old  method  of  injection  into  the  mucosa  is  successful  only  in  certain 
favorable  cases;  generally  it  spells  more  or  less  complete  failure. 


MUCOUS    ANESTHESIA    BY    INFILTRATION. 

By  mucous  anesthesia  we  mean  anesthesia  of  a  circumscribed 
portion  of  the  jaw  induced  by  way  of  the  oral  mucosa.  The  course  of 
this  anesthesia  varies  according  to  the  condition  of  the  mucous  mem- 
brane, the  manner  of  insertion  of  the  needle,  and  the  pressure  under 
which  the  solution  is  injected  into  the  tissues.  By  infiltrating  a  tissue 
area  with  an  anesthetic  solution,  the  functions  of  the  nerves  supplying 
that  area  are  paralyzed.  In  every  case  the  anesthetic  effect  is  due 
to  the  contact  of  the  injected  solution  with  the  sensory  nerve  fibers, 
which  are  gradually  paralyzed  within  from  five  to  ten  minutes,  depend- 
ing upon  the  anesthetic  employed.  If  injected  correctly,  our  novocain- 
suprarenin  solution  produces  complete  anesthesia  of  the  injected  area 
within  from  eight  to  ten  minutes.      The  anesthesia  maintains  its  full 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


179 


intensity  for  about  half  an  hour,  after  which  time  it  wears  off  very 
gradually. 

Since  mucous  anesthesia  in  the  jaws  depends  primarily  upon 
injection  into  the  periosteum  and  the  tissue  elements  connected  with 
it,  while  the  mucous  membrane  proper  is  of  but  secondary  importance, 


Fig.  72 


Mucous  anesthesia  in  the  maxilla  in  case  of  abscess  of  the  root  of  the  upper  left  canine.  The 
needle  is  inserted  in  the  gingival  papilla  of  the  central  incisor  and  advanced  horizontally  in  distal 
direction.    Injection  is  made  into  the  periosteum.    The  syringe  is  held  like  a  penholder. 


it  would  be  more  correct  to  speak  of  periosteal  anesthesia.  Success 
depends  not  so  much  upon  injection  into  the  submucous  tissue  as  into 
the  periosteum.  The  periosteum  of  the  maxillae  forms  an  extremely 
taut  and  firm  layer,  and  injection  below  this  layer  requires  considerable 
pressure. 


180 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Injection  in  the  Mucosa. — The  syringe  is  held  like  a  penholder 
(see  Fig.  72),  and  the  needle  is  placed  at  an  almost  right  angle  upon 
the  mucosa,  which  has  previously  been  disinfected  with  tincture  of 
iodin.     The  needle  is  then  slowly  pushed  through  the  gingiva  and  the 

Fig.  73 


Points  of  injection  for  anterior  upper  teeth.  I,  injection  for  abscessed  upper  left  lateral  incisor; 
2,  injection  for  upper  right  central  and  lateral  incisors;  3,  injection  for  upper  right  canine;  4,  injec- 
tion for  upper  right  bicuspid.  The  red  crosses  indicate  the  points  of  injection,  the  red  arrows  the 
direction  of  the  needle. 

Fig.  74 


Labial  surface 


Correct 


Correct 


Palatal  surface  \ 


Incorrect 
Incorrect 
Diagram  showing  method  of  injection  in  maxilla  (upper  right  canine).     The  red  arrows  indicate  the 
correct,  the  black  arrows  the  incorrect  position  of  the  needle. 

periosteum,  and  the  syringe  is  inclined  so  that  the  needle  forms  an 
acute  angle  with  the  bone  (see  Figs.  73  and  74).  The  syringe  is  then 
held  in  this  position  with  the  left  hand,  while  the  right  hand  moves 
back  along  the  barrel  until  it  engages  the  piston  handle  and  cross 
bar  between  the  thumb  and  the  index  and  middle  fingers. 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


181 


The  syringe  is  mounted  with  hub  B  or  C  and  needle  No.  17  a  (see 
Figs.  75  and  76).  The  orifice  of  the  needle  should  always  point  toward 
the  bone  in  the  manner  illustrated  in  Fig.  77.  With  the  fingers  of  the 
left  hand,  the  lip  is  lifted  up  as  high  as  possible  to  gain  an  unobstructed 


Syringe  mounted  with  hub  B  and  needle  Xo. 
17a,  for  injection  in  anterior  teeth. 


Syringe  mounted  with  hub  C  and  needle  No. 
17  a,  for  injection  in  anterior  teeth. 


field  of  vision  (see  Fig.  72),  and  the  correct  quantity  of  solution,  as 
indicated  in  the  tables  on  page  233,  is  injected  without  advancing  the 
needle  farther  along  the  bone.  The  syringe  is  then  cautiously  and 
slowly  withdrawn,  and  the  point  of  injection  is  compressed  with  the 
index  finger  of  the  free  hand  for  about  fifteen  seconds. 


182 


TECHNIQUE  OF  LOCAL  ANESTHESIA 

Fig.  77 


4  ^ 

Position  of  the  needle  in  mucous  anesthesia,  the  aperture  of  the  needle  pointing  toward  the  bone, 
a,  correct  position;  h,  incorrect  position.  The  point  of  the  needle  is  forced  into  the  periosteum  and 
to  the  bone.     (After  Seidel.) 


Fig.  78 


Points  of  injection  in  the  maxilla  in  mucous  and  conductive  anesthesia.  Z7,  line  of  reflection  of 
mucous  membrane;  i,  injection  for  upper  right  central  incisor;  2,  for  upper  right  lateral  incisor;  3,  for 
conductive  anesthesia  of  upper  right  lateral,  canine,  and  first  bicuspid,  the  needle  to  be  advanced 
to  the  infra-orbital  foramen;  4,  for  upper  right  second  bicuspid;  5,  for  upper  right  first  molar;  6, 
conductive  anesthesia  at  maxillary  tuberosity  for  upper  right  first,  second,  and  third  molars;  7, 
conductive  anesthesia  for  upper  right  third  molar. 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


183 


In  the  posterior  portions  of  the  gums,  owing  to  the  interference  of 
the  cheek,  the  needle  cannot  be  inserted  at  a  right  angle^  and  must 
therefore  be  advanced  obHquely  (see  Figs.  78  and  80).  In  this  case 
the  syringe  is  mounted  with  hub  A  and  needle  No.  17  c. 

Fig.  79 


Syringe  mounted  with  hub  B  and  needle  No.  17  c,  for  injection  in  posterior  teeth. 

Maxilla. — Buccal  and  Labial  Injection. — Injections  in  the  buccal 
mucosa  also  are  generally  made  in  the  manner  just  described.  Repeated 
insertions  of  the  needle  should  be  avoided  as  much  as  possible,  and  an 
effort  be  made  to  infiltrate  the  desired  area  at  one  insertion,  which  is 
always  possible  in  single  teeth.  The  anesthetization  even  of  several 
teeth    can    be    accomplished    at    one    buccal    insertion,   especially    in 


184 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


bicuspids  and  molars,  which  allow  nearly  straight  advancement  of  the 
long  needle  (see  Fig.  80).      In  these  teeth  the  needle  is  inserted  at  the 


Fig. 


Position  of  the  needle  for  horizontal  injection  in  several  upper  teeth.     Needle  yellow;  a,  labial 

injection;  b,  buccal  injection. 


Fig.  81 


Position  of  the  needle  for  injection  in  upper  canine.    Needle  yellow:  a,  labial  injection; 

b,  palatal  injection. 


level  of  the  middle  root  portion  at  a  right  angle  to  the  long  axis  of 
the  teeth. 


MUCOUS  ANESTHESIA   BY  INFILTRATION  185 

At  the  sharp  curve  in  the  canine  region,  however  (see  Fig.  80), 
the  needle  is  inserted  at  the  level  of  the  root  apex  of  the  canine  and 
advanced  into  the  depth  of  the  gingiva,  where  the  injection  is  slowly 
made  under  pressure  (see  Fig.  81).  If  the  incisors  and  bicuspids  on 
the  same  side  are  also  to  be  anesthetized,  the  needle  is  pushed  forward 
from  the  canine  root,  slowly  discharging  the  contents  of  the  barrel, 
in  the  direction  of  the  anterior  nasal  spine  to  the  region  of  the  root 
apex  of  the  central  incisor,  where  the  remainder  of  the  solution  is 
injected  (see  Fig.  78).     After  the  syringe  has  been  refilled,  the  needle 

Fig.  82 


b 

Position  of  the  needle  for  mucous  anesthesia  in  upper  first  bicuspid.    Needle  yellow.    Above  is  seen 
the  infra-orbital  foramen:  a,  buccal  injection;  h,  palatal  injection. 

is  again  inserted  at  the  former  point  at  the  canine  root,  but  advanced 
in  the  direction  of  the  root  apices  of  the  bicuspids,  where  the  barrel 
is  again  slowly  discharged.  If  the  second  bicuspid  also  is  to  be  anes- 
thetized, the  needle  must  be  advanced  to  the  root  apex  of  that  tooth 
(see  Fig.  82). 

If  the  gingival  tissue  is  normal,  no  wheal  is  usually  raised,  and 
the  formerly  pink  mucous  membrane  becomes  pale.  In  spongy  gingival 
tissue,  however,  the  formation  of  a  wheal  cannot  be  prevented.  The 
gradual   expansion    of   the    anemic    area   should    always    be   carefully 


186 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


noted.  This  observation  is  greatly  facilitated  if  one  of  the  colorless 
iodin  preparations,  as  advocated  on  page  96,  is  used  for  disinfecting 
the  mucosa  prior  to  injection,  instead  of  ordinary  tincture  of  iodin. 
After  a  successful  injection  the  anemia  frequently  extends  to  the 
palate,  owing  to  the  diffusion  of  the  solution  within  the  interdental 
papilla. 

Fig.  83 


Injection  in  the  palatal  mucous  membrane  at  the  lateral  incisor.    The  syringe  is  held 

like  a  penholder. 

Palatal  Injection. — The  induction  of  mucous  anesthesia  from  the 
palatal  surface  of  the  maxilla  requires  special  description.  For  palatal 
injection  the  needle  is  always  inserted  in  the  mucosa  behind  the  tooth 
to  be  anesthetized  (see  Figs.  74,  80  to  83)  and  is  at  once  cautiously 
and  slowly  advanced  parallel  with  the  alveolar  process  to  the  vicinity 
of  the  root  apex  (see  Figs.  74  and  84),  where  a  small  quantity  of  the 
solution,  i.  e.,  from  -|-    to  ^  c.c,  is    deposited    (see    Fig.   73).      In  the 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


187 


deep  stratum  of  the  anterior  palatine  area  the  conditions  for  diffusion 
are  most  favorable,  and  the  injection  can  be  made  much  more  easily, 
and  with  less  pressure  and  pain,  than  near  the  cervical  margin  of  the 
gingival  tissue,  where  the  taut  circular  ligament  offers  considerable 
resistance  (see  Figs.  85  and  86). 

Fig.  84 


Injection  in  the  palatal  mucous  membrane  in  the  bicuspid  region.    The  syringe  is  held 

like  a  penholder. 


Injection  at  the  Posterior  Palatine  Foramen. — The  above  procedure 
is  repeated  for  all  upper  incisors,  canines,  and  bicuspids,  but  is  not 
followed  in  the  upper  molars.  In  these,  one  single  injection  at  the 
posterior  palatine  foramen  suffices,  this  foramen  being  situated  under 
a  slight  depression  in  the  mucosa  near  the  palatal  root  apex  of  the 
third  molar  (see  Pig.  87),  The  posterior  palatine  foramen  is  usually 
located   ^   cm.  from   the  posterior  border  of  the  alveolar  process  and 


188 


TECHNIQUE  OF  LOCAL  ANESTHESIA 
Fig.  85 


Posterior  pal- 
atine fora- 
men 


Bony  surface  of  palate.    The  red  crosses  indicate  the  points  of  injection  for  mucous  anesthesia;  the 
solid  red  arrows  the  points  of  injection  at  the  posterior  palatine  foramina. 


Fig. 


Position  of  the  needle  for  injection  in  upper  central  incisor.     Needle  yellow:  a,  labial   injection, 

b,  palatal  injection. 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


189 


above  the  last  erupted  molar  (see  Figs.  54,  85,  and  87),  viz.:  up  to 
the  tenth  or  eleventh  year  above  the  first  molar,  after  the  eruption 
of  the  second  molar  above  this  tooth,  and  finally,  above  the  third 
molar  (see  Figs.  32  to  35,  54  and  78).  If  the  posterior  portion  of  the 
alveolar  process  has  been  absorbed,  it  is  best  to  inject  near  the  apex 
of  the  palatal  root  of  the  first  or  second  molar  to  be  anesthetized. 

Fig.  87 

Central 
Lateral    incisor  Incisive  papilla 
incisor        |  f 

Canine  \      > — >  ■ 


Bicuspids 


Molars 


Point  of  injection 
at  posterior  pal- 
atine foramen 


Palato-maxillary  ,^- 
depression 

Soft  palate 


Palatal 
raphe 

..,.  Point  of  injection 
at  posterior  pal- 
atine foramen 


■^:^  Orifices  of  pal- 
atine glands 


# 


_.   Anterior  pillar 


—  z —  Posterior  pillar 


Uvida 

Mucous  surface  of  palate.    The  red  cross  marks  the  point  of  injection  at  the  posterior  palatine 
foramen  on  either  side.     (After  Spalteholz.) 


The  needle  is  inserted  into  the  depression  in  the  mucosa  at  about 
the  level  of  the  palatal  root  apex  of  the  second  molar,  the  syringe 
being  directed  almost  parallel  to  the  alveolus  and  the  molar  root  and 
inclined  slightly  backward  toward  the  tuberosity;  the  needle  is  then 
advanced  into  the  foramen  and  from  6  to  10  drops  of  the  solution 
are  evacuated.  The  discharge  of  a  larger  quantity  involves  danger 
of  the  solution  diffusing  int(^  the  loose  tissue  of  the  soft  palate  and 


190 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


causing  disagreeable  difficulties  in  deglutition.  Strictly  speaking,  a 
conductive  anesthesia  is  induced  by  this  method,  as  the  anterior 
palatine  nerve  trunk  is  blocked  at  its  descent  from  the  posterior  pala- 
tine foramen.  The  palatal  portion  of  the  alveolus  in  the  molar  region 
is  completely  anesthetized  by  this  injection. 


Fig. 


Bidge- 


Body  of  mandible 


^  Angle 


Oblique  line 


■Line  of  reflection 
of  mucous  mem- 
bi-ane 


Mental  foramen 


Mental  pro- 
tuberance 


Points  of  injection  for  mucous  anesthesia  in  external  surface  of  mandible.  Red  crosses  indicate 
points  of  injection;  small  red  arrows,  direction  of  needle;  two  large  arrows,  direction  of  needle  for 
injection  in  mental  foramen  and  fossa.  On  the  internal  surface  of  ramus  are  marked  the  points  for 
injection  at  mandibular  foramen. 


Injection  in  the  Anterior  Palatine  Fossa  Contra-indicated. — Experi- 
ence has  shown  that  the  anterior  palatine  fossa  with  its  four  foramina, 
situated  in  the  anterior  portion  of  the  palatal  roof,  is  not  a  suitable 


MUCOUS  ANESTHESIA   BY  INFILTRATION 

Fig.  89 


191 


Position  of  the  needle  for  injection  in  lower  molars.     Needle  yellow;  a,  buccal  injection; 

h,  lingual  injection. 


Fig.  90 


Injection  in  the  mandibular  mucous  membrane  for  anesthesia  of  lower  second  bicuspid.  The 
needle  is  inserted  in  the  eminence  at  the  first  bicuspid  directly  below  the  gingival  papilla. 
The  syringe  is  held  like  a  penholder. 


192 


TECHNIQUE  OF  LOCAL  ANESTHESIA 

Fig.  91 


Injection  for  anesthesia  of  lower  anterior  teeth.    The  long  needle  is  inserted  in  the  reflection  of  the 
mucous  membrane  and  advanced  to  the  mental  fossa.     The  syringe  is  held  like  a  penholder. 


Position  of  the  needle  for  injection  in  lower  canine.     Injection  in  mental  fossa.     Needle  yellow: 

a,  labial  injection;  h,  lingual  injection. 


MUCOUS  ANESTHESIA   BY  INFILTRATION 


193 


site,  as  an  injection  at  this  point  for  the  purpose  of  anesthetizing  the 
nasopalatine  nerve  usually  produces  severe  pain,  due  possibly  to  the 
presence  of  a  specially  large  number  of  sensory  fibers  in  the  incisive 
papilla.  Moreover,  no  advantages  in  regard  to  effect  are  to  be  derived 
from  such  an  injection,  and  palatal  injection  behind  each  tooth,  as 
advocated  (see  Figs.  74,  83,  and  84),  is  more  expedient,  successful,  and 
easily  tolerated,  causing  a  minimum  of  pain. 

Fig.  93 


Mandibular 
foramen^^ 


/    Genial  tubercles 


Cor  on  Old 
1  process 


■"  ~  -,  ^  Condyloid 
process 


Lingual  points  of  injection  for  mucous  anesthesia  of  the  mandible.  Red  crosses  indicate  the 
points  of  injection;  red  arrows,  the  direction  of  the  needle;  black-dotted  lines,  the  angle  of  the  ramus 
to  the  body  of  jaw. 

Mandible. — In  the  mandible  mucous  anesthesia  is  limited  to 
anesthetization  of  loose  roots  and  teeth,  and  may  sometimes  render 
good  service  in  the  anterior  teeth  (see  Fig.  88). 

Injection  in  the  Gingival  Papillce  in  the  Mandible.- — Mucous  anes- 
thesia of  the  lower  anterior  teeth  must  be  clearly  distinguished  from 
anesthesia  of  the  posterior  teeth,  including  the  first  bicuspid.  While 
in  the  latter  teeth  injection  is  always  made  in  the  region  of  the  gingival 
papillae,  advancing  the  needle  horizontally  along  the  alveolar  margin 
(see  Figs.  88  and  89),  which  is  the  only  place  favorable  for  diffusion 

13 


194 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


into  the  fundus  of  the  alveoli  (see  Figs.  45,  48,  and  88),  anesthesia 
of  the  anterior  teeth,  including  the  canines,  is  obtained  in  the 
following  manner: 

Injection  in  the  Mental  Fossa. — The  lip  is  depressed  and  the  needle 
inserted  in  the  reflection  of  the  mucous  membrane,  which  has  been 
previously  sterilized  with  tincture  of  iodin,  at  about  the  level  of  the 
root  apex  of  the  canine  (see   Figs.  91   and  92),  and   pushed   forward 


Fig.  94 


Lingual  injection  between  lower  canine  and  bicuspid  for  anesthesia  of  lingual  nerve  fibers.    Mucous 

anesthesia. 


and  downward  with  a  slight  inclination  mesially,  until  the  mental  fossa 
is  reached  (see  Figs.  16  to  22,  24  to  28,  91  and  92).  This  fossa  is 
situated  below  the  root  apices  of  the  canine  and  the  lateral  incisor,  and 
usually  has  numerous  foramina  through  which  the  injected  solution 
penetrates  into  the  interior  of  the  jaw  (see  Figs.  16  to  29).  While 
advancing  the  needle,  a  few  drops  of  the  solution  are  discharged;  the 
bulk  of  solution  (about  i  c.c),  however,  is  injected  in  the  fossa  itself, 


MUCOUS  ANESTHESIA   BY  INFILTRATION  195 

and  invariably  produces  complete  anesthesia  of  the  canine  and  the 
two  incisors  on  the  injected  side. 

Lingual  Injection. — Lingually  a  small  quantity  of  solution  is  injected 
behind  the  central  incisors  and  in  the  line  of  their  long  axis  (see  Fig. 
93),  also  between  the  canine  and  the  first  bicuspid  (see  Fig.  94),  in 
order  to  anesthetize  the  filaments  of  the  lingual  nerve  (see  Fig.  58) 
as  well  as  to  force  the  solution  into  the  interior  of  the  jaw  through 
the  foramina  situated  lingually  at  the  internal  genial  tubercles  (see 
Figs.  36  and  37).  The  needle  is  inserted  below  the  tense  gingival  papilla 
of  the  central  incisor,  and  is  at  once  slowly  advanced  parallel  to  the 
alveolar  process,  while  discharging  some  solution,  to  the  vicinity 
of  the  root  apex.  An  injection  is  also  made  between  the  canine  and 
bicuspid  (see  Figs.  92  and  94),  the  needle  being  advanced  directly 
to  about  the  middle  of  the  canine  root,  while  slowly  discharging  some 
solution;  in  both  cases  about  %  c.c.  of  solution  is  injected.  While 
in  the  anterior  lower  teeth  it  is  possible  to  inject  locally,  yet,  if  several 
teeth  are  to  be  anesthetized  simultaneously,  it  is  preferable  to  resort 
to  conductive  anesthesia,  which  insures  full  success  even  in  periostitis, 
and  is  attained  more  rapidly  and  simply  by  blocking  the  entire  man- 
dibular nerve  trunk,  if  necessary,  on  either  side. 

Anesthesia  of  Lower  Molars. — In  the  lower  molars  conductive 
anesthesia  alone  is  indicated. 

Anesthesia  in  Inflammatory  Conditions. — Mucous  Anesthesia  in 
Inflammatory  Swelling. — In  cases  of  gingival  or  alveolar  abscess, 
conductive  anesthesia  should  always  be  first  attempted.  If  this, 
however,  is  unsuccessful  or  contra-indicated,  anesthesia  of  the  mucosa 
by  means  of  the  ether  spray  is  the  last  and  only  resort. 

Anesthesia  by  Ethyl  Chlorid. — In  the  anterior  teeth,  both  upper 
and  lower,  the  old  ether  spray  method  can  often  be  employed  with 
great  success.  The  diseased  mucosa  is  carefully  dried  and  disinfected 
with  tincture  of  iodin;  right  and  left  of  the  field  of  operation  the  gingivae 
are  padded  with  cotton  rolls  in  order  to  keep  away  the  saliva  as  much 
as  possible,  the  tongue  is  covered  with  a  small  mouth  napkin,  and  the 
ethyl  chlorid  spray  from  an  automatically  closing  flask  is  directed 
against  the  mucous  membrane,  from  a  distance  of  from  20  to  30  cm. 


196  TECHNIQUE  OF  LOCAL  ANESTHESIA 

If  perfectly  dry,  the  mucosa  is  rapidly  covered  by  a  crust  of  ice  and 
congealed.  After  about  one  minute  the  tooth  can  be  extracted,  and 
in  most  cases  such  operations  are  painless,  or  at  least  very  tolerable. 

In  extracting  putrescent  deciduous  teeth  this  method  is  particu- 
larly practical,  since  the  ether  inhaled  by  the  child  produces  a  light 
narcosis  sufficient  to  render  the  operation  painless.  Ethyl  chlorid 
is  indispensable  also  in  severe  putrescent  conditions,  in  incisions  for 
gumboils,  or  in  extraction  of  loose  putrescent  anterior  teeth  or  roots. 
In  such  cases  anesthesia  by  local  injection  would  be  detrimental  rather 
than  useful.  The  risk  of  infiltrating  an  abscessed  or  inflamed  area 
is  too  great,  as  general  sepsis  might  be  induced  with  possibly  fatal 
results. 

Fig.  95 


Diagram  showing  method  of  peripheral  injections  in  abscessed  areas. 

If,  nevertheless,  mucous  injection  is  preferred  to  the  far  more 
efficacious  and  safe  conductive  method,  the  injection  must  always 
be  made  in  healthy  mucous  membrane  in  the  vicinity  of  the  focus  of 
infection  (see  Figs.  ^2,  73  and  95).  In  such  cases,  however,  several 
l)eripheral  injections  on  each  side  of  the  abscess  must  be  made,  and 
the  solution  discharged  immediately  upon  iuvserting  the  needle  and 
without  advancing  it. 

Injection  in  Swollen  Areas. — Figure  73  illustrates  the  method  of 
anesthetizing  a  putrescent  upper  lateral  incisor  when  swelling  is 
present.  One  injection  is  made  above  the  central  incisor  in  the  direc- 
tion of  the  root  apex  of  this  tooth,  a  second  injection  slightly  above 
the  gingival  margin  of  the  lateral  incisor  in  distal  direction,  provided 
no  abscessed  tissue  is  met  with.    The  third  and  final  injection  is  made 


PERIDENTAL  AND  INTRA-OSSEOUS  INJECTIONS  197 

above  the  canine,  the  needle  to  be  advanced  in  the  direction  of  the 
canine  fossa.  In  all  these  cases  the  needle  is  advanced  directly  to  the 
periosteum,  and  the  solution  is  injected  slowly  and  under  moderate 
pressure.  As  soon  as  the  patient  perceives  a  painful  sensation  of 
tension,  the  injection  at  that  point  must  be  immediately  discontinued. 
Digital  compression  of  the  place  of  insertion  of  the  needle  is  again 
of  the  greatest  value. 

Period  of  Waiting. — In  all  cases  of  mucous  anesthesia,  a  waiting 
period  of  from  eight  to  ten  minutes  must  be  allowed.  The  anesthesia 
lasts  from  twenty  to  sixty  minutes. 

Principles  of  Mucous  Anesthesia. — Besides  the  cautionary  meas- 
ures enumerated  before,  such  as  asepsis,  isotonia  of  the  solution, 
etc.,  the  following  technically  important  factors  must  be  observed  to 
insure  a  successful  mucous  anesthesia: 

1.  Application  of  the  stasis  bandage  in  delicate  and  anemic 
patients,  or  those  with  heart  disease. 

2.  Thorough  sterilization  of  the  mucosa  with  tincture  of  iodin 
(decolorized  iodin  or  thymol-alcohol). 

3.  Infiltration  of  the  gingiva. 

4.  One  injection  on  each  side  of  the  jaw;  the  fewer  needle-pricks 
the  better  the  effect. 

5.  The  orifice  of  the  sterile  needle  (preferably  of  iridioplatinum) 
must  always  point  toward  the  bone. 

6.  Slow,  moderately  strong  pressure  during  the  injection. 

7.  Compression  of  the  point  of  injection  with  the  finger  tip  after 
withdrawal  of  the  needle. 

8.  A  waiting  period  of  from  eight  to  ten  minutes. 

9.  The  patient  should  be  kept  under  observation  after  the 
injection. 


PERIDENTAL    AND    INTRA-OSSEOUS    INJECTIONS. 

Peridental  Injection. — The  methcjds  of  peridental  and  intra-osseous 
anesthesia  are  here  mentioned   merely   for  the  sake  of  completeness; 


198  TECHNIQUE  OF  LOCAL  ANESTHESIA 

for  practice  they  are  to  be  discountenanced,  since  they  offer  no 
advantage  whatever,  and  are  compHcated  and  dangerous.  Peridental 
anesthesia,  which  has  been  recommended  by  various  writers,  is  best 
described  by  H.  Prinz:^ 

"Teeth  or  roots  standing  singly,  or  teeth  affected  by  pyorrhea  or 
similar  chronic  peridental  disturbances,  are  frequently  quickly  and 
satisfactorily  anesthetized  by  injecting  the  fluid  directly  into  the 
peridental  membrane.  This  method  is  known  as  peridental  anesthesia, 
and  its  technique  is  very  simple.  In  single-rooted  teeth  a  fine  and 
short  hypodermic  needle  is  inserted  under  the  free  margin  of  the  gum, 
or  through  the  interdental  papilla,  into  the  peridental  membrane 
between  the  tooth  and  the  alveolar  wall.  Sometimes  the  needle  may 
be  forced  through  the  thin  alveolar  bone  so  as  to  reach  the  peridental 
membrane  directly.  To  gain  access  to  this  membrane,  in  teeth  set 
closely  together,  separation  is  essential.  It  may  be  accomplished 
with  an  orange-wood  stick  or  by  any  of  the  various  mechanical  separa- 
tors. By  so  doing  the  body  of  the  tooth  is  shifted  to  one  side,  thereby 
creating  a  slight  space  between  it  and  the  alveolar  process.  The 
injection  is  now  made  directly  into  the  exposed  peridental  membrane. 
By  reversing  the  separator,  the  tooth  is  shifted  to  the  opposite  side, 
and  the  injected  liquid  is  forced  toward  the  apex  of  the  tooth.  A 
second  injection  is  now  made  in  this  freshly  exposed  portion  of  the 
peridental  membrane.  Two,  sometimes  three,  injections  are  necessary. 
To  force  the  liquid  into  the  membrane  usually  requires  a  higher  pres- 
sure than  that  which  is  necessary  for  injecting  into  the  periosteum 
covering  the  alveolar  process,  but  the  quantity  of  the  anesthetic 
liquid  is  less  than  that  which  is  required  for  the  former  injection. 
Acute  inflammatory  conditions  of  the  peridental  membrane  and  its 
sequelae  prohibit  the  use  of  this  method.  Peridental  anesthesia  is 
the  purest  form  of  local  anesthesia,  since  the  seat  of  the  nerve  supply 
of  the  tooth  is  very  quickly  reached,  and  as  a  consequence  the  results 
obtained  are  in  the  majority  of  cases  extremely  satisfactory,  provided 
that  general  conditions  justify  its  application.  The  method  is  spe- 
cially serviceable  for  the  removal  of  pulps  in  all  such   cases  where 

1  Dental  Summary,  March,  1912,  p.  167. 


PERIDENTAL  AND  INTRA-OSSEOUS  INJECTIONS  199 

contact  anesthesia  is  not  indicated,  or  for  temporarily  desensitizing  a 
tooth  for  operative  procedures." 

This  description  of  peridental  injection  contains,  step  by  step,  a 
condemnation  of  that  method.  It  is  evidently  harmful  and  dangerous 
to  inject  any  solution  directly  into  an  infected  field,  such  as  may 
surround  teeth  or  single  roots  affected  by  pyorrhea  or  similar  chronic 
peridental  disturbances;  for  infectious  material  is  invariably  carried 
to  deeper  strata,  especially  under  the  great  pressure  required  in  this 
form  of  injection.  This  procedure  cannot  but  produce  severe  after- 
pain,  sloughing,  necrosis,  or  constitutional  septic  symptoms  (as 
described  in  Dr.  Marshall's  case  on  page  113),  all  of  which  misfortunes 
are  then  usually  laid  at  the  door  of  "the  toxicity  of  the  anesthetic." 
The  procedure  of  separating  the  teeth  in  order  to  gain  access  for  the 
insertion  of  the  needle  between  the  tooth  and  the  alveolar  process  is 
dreaded  by  every  patient,  and  the  preliminary  measures  for  preparing 
the  field  for  injection  involved  in  this  method  are  almost  as  painful 
as  the  operation  would  be  without  the  local  anesthetic,  while  sub- 
mucous and  conductive  injections  as  advocated  in  this  book,  if  executed 
correctly,  produce  no  pain  whatever.  The  fact  that  a  slightly  smaller 
quantity  of  anesthetic  solution  is  required  is  a  negligible  factor,  con- 
sidering the  very  small  doses  required  in  the  methods  advocated  herein, 
which  are  so  very  far  below  the  toxic  limit.  In  healthy  single  teeth 
peridental  injection  is  painful  owing  to  the  extremely  tense  nature 
of  the  membrane,  which,  moreover,  it  is  an  accepted  rule  not  unneces- 
sarily to  injure,  as  such  injury  may  prove  fatal  to  the  life  of  the  tooth. 

Intra-osseous  Injection. — Intra-osseous  injection,  for  the  purpose 
of  hastening  the  diffusion  of  the  anesthetic  solution,  was  suggested 
by  Otte  in  1896,  and  again,  independently  of  him,  by  A.  H.  Parrott.^ 
Various  modifications  of  this  method  have  been  proposed,  as,  for 
instance,  by  B.  H.  Masselink.-  The  technique  of  this  method  is  as 
follows,  excluding  minor  details:  "After  the  gum  tissue  is  thoroughly 
cleansed  with  an  antiseptic  solution,  it  is  anesthetized  about  the  neck 
of  the  tooth  in  the  usual  manner.  After  waiting  two  or  three  minutes, 
an  opening  is  made  into  the  gum  tissue  and  the  bone  on  the  buccal 

'  British  Dental  Journal,  August  16,  1909.  -  Dental  Cosmos,  August,  1910,  p.  868. 


200  TECHNIQUE  OF  LOCAL  ANESTHESIA 

side  with  a  round  bur,  a  fine  spear  drill  or  a  Gates-Glidden  drill.  The 
opening  should  be  made  more  or  less  at  a  right  angle,  with  the  long 
axis  of  the  tooth  a  little  below  the  apical  foramen  in  single-rooted 
teeth,  or  between  the  bifurcation  in  molars.  The  right-angle  hand- 
piece is  preferably  employed  for  this  purpose.  The  drill  should  be 
of  the  same  diameter  as  the  hypodermic  needle.  The  gum  fold  is 
tightly  stretched  to  avoid  laceration  for  the  rapidly  revolving  drill. 
As  soon  as  the  alveolar  process  is  penetrated,  a  peculiar  sensation 
conveyed  to  the  guiding  hand  indicates  that  the  alveolus  proper  is 
reached,  and  the  sensation  felt  by  the  hand  is  about  the  same  as  that 
experienced  when  a  bur  enters  into  the  pulp  chamber.  In  this  arti- 
ficial canal  the  closely  fitting  short  hypodermic  needle  with  a  blunt 
point  is  then  inserted,  and  the  injection  is  made  in  the  ordinary  way." ^ 
From  this  description  it  is  self-evident  that  the  method  of  intra- 
osseous injection  is  complicated  and  risky.  Inasmuch  as  a  preliminary 
injection  is  required  for  the  painless  employment  of  the  bur,  this 
injection  might  as  well  be  executed  in  such  a  manner  as  to  render  any 
adjuvant  injection  unnecessary.  The  uncertainty  of  the  effect  of  the 
bur  upon  the  tissues  within  the  alveolus;  the  danger  of  lacerating 
the  gingiva,  or  injuring  nerves  or  bloodvessels;  the  probability  of 
infection  by  way  of  the  handpiece,  that  bugbear  of  sterilization;  the 
not  inconsiderable  lesion  produced  by  the  bur,  which  is  not  justified 
by  the  result  to  be  attained;  the  obscurity  in  regard  to  the  actual 
topography  of  the  root,  if  no  radiograph  is  available,  and  the  likelihood 
of  a  disturbed  healing  process — all  these  considerations  characterize 
the  intra-osseous  method  as  one  in  nuce. 


CONDUCTIVE    ANESTHESIA. 

When  injected  in  the  vicinity  of  a  fair-sized  nerve  trunk,  an  anes- 
thetic solution  penetrates  by  way  of  the  perineurium  into  the  central 
nerve  substance,  inhibiting  its  function,  and  anesthetizing  the  entire 
peripheral  area  supplied  by  that  nerve.     Owing  to  this  elimination  of 

1  Prinz,  Dental  Summary,  March,  1912,  p.  169. 


CONDUCTIVE  ANESTHESIA  201 

the  conductivity  of  the  nerve  trunk,  sensory  irritations  of  its  terminal 
filaments  are  no  longer  perceived  in  the  central  organ.  "The  sensory 
nerve  tracts  are  extremely  susceptible  to  anesthesia  by  perineurial 
injection,  if  their  minute  terminal  branches  are  inundated  with  an 
anesthetic  solution;  conductive  anesthesia,  on  the  other  hand,  is  more 
difficult,  ensues  more  slowly,  and  requires  a  larger  quantity  and  a 
higher  concentration  of  anesthetic  solution,  the  farther  away  from 
the  terminal  distribution  of  the  nerves,  i.  e.,  the  nearer  to  the  spinal 
column  an  injection  is  made."      (Braun.) 

This  contention  is  fully  borne  out  by  practical  experience  with 
anesthesia  of  the  jaws.  The  nerve  terminals  of  the  periosteum  and 
the  pericementum  are  anesthetized  in  the  most  direct  and  expedient 
way,  often  within  five  minutes,  by  mucous  anesthesia.  Anesthesia 
by  injection  at  the  maxillary  tuberosity,  which  represents  a  modified 
form  of  conductive  anesthesia,  ensues  with  almost  equal  rapidity, 
i.  e.,  in  ten  minutes.  Mandibular  conductive  anesthesia  requires 
the  longest  period,  viz.,  twenty  minutes,  because  the  large  inferior 
dental  nerve  must  be  reached  and  permeated  by  the  anesthetic. 

For  our  purposes,  the  following  methods  of  conductive  anesthesia 
are  the  most  practical:  (i)  In  the  maxilla,  {a)  injection  at  the  maxil- 
lary tuberosity;  {h)  in  some  cases,  infra-orbital  injection.  (2)  In  the 
mandible,  injection  at  the  mandibular  or  inferior  dental  foramen. 

Topography  of  the  Maxilla. — The  anatomic  details  described 
below  have  been  compiled  with  the  cooperation  of  the  Marburg  Ana- 
tomic Institute.  The  illustrations  are  reproductions  of  original  speci- 
mens made  by  Professor  Gasser,  who  has  made  specially  careful 
investigations  of  our  field  of  operation.  According  to  this  expert  in 
anatomic  technique,  the  topography  of  the  portions  concerned  in 
local  anesthesia  can  be  determined,  in  addition  to  visual  examination 
and  palpation  in  the  living,  in  the  following  manner: 

1.  By  sections  through  the  region  to  be  studied;  if  practical,  by 
frozen  sections; 

2.  By  dissected  specimens. 

The  former  method  affords  a  most  accurate  insight  into  the  ana- 
tomic arrangement  of  the  part,  since  nothing  is  dissected  away;  each 


202  TECHNIQUE  OF  LOCAL  ANESTHESIA 

section,  however,  shows  only  one  level.  The  latter  method  offers  the 
advantage  of  a  comprehensive  survey  of  the  entire  part.  Both  methods 
have  been  used. 

Infra-orbital  Nerve. — The  topography  of  the  superior  maxillary  or 
infra-orbital  nerve,  as  it  passes  through  the  infra-orbital  canal  in  the 
floor  of  the  orbit,  is  shown  in  Fig.  96.  In  the  specimen  illustrated, 
the  zygomatic  arch  together  w^th  the  masseter  muscle  is  removed, 
first  exposing  the  mandible  and  the  temporal  muscle.  The  anterior 
portion  of  the  ascending  ramus  and  the  head  of  the  temporal  muscle 
are  removed  next.  In  this  way  the  pterygoid  fissure  with  the  lingual 
and  mandibular  nerves  and  the  inferior  dental  artery  are  exposed.  The 
upper  portion  of  the  external  pterygoid  muscle  is  reflected.  The 
posterior  portion  of  the  buccinator  muscle  is  shown  with  its  charac- 
teristic curvature  before  it  continues  downward  and  backward.  This 
curvature,  which  is  in  direct  contact  with  the  mucosa  of  the  cheek, 
indicates  the  lateral  and  posterior  border  of  the  oral  cavity.  Above 
the  buccinator  muscle  appears  the  maxillary  tuberosity,  above  which 
the  entrance  to  the  infra-orbital  canal  is  situated.  Behind  lies  the 
pterygoid  process  and  the  pterygopalatine  fossa,  covered  by  the 
maxillary  bone. 

The  arch  of  the  internal  maxillary  artery  disappears  in  the  pterygoid- 
palatine  fossa.  The  ijifra-orbital  and  the  posterior  superior  dental 
nerves  are  visible.  It  should  be  remembered  that  the  superior  dental 
nerves  are  branches  of  the  infra-orbital:  the  posterior  superior  dental 
nerves  arise  from  the  trunk  of  the  nerve  just  as  it  is  about  to  enter 
the  infra-orbital  canal,  and  pass  downward  on  the  maxillary  tuber- 
osity; the  middle  and  anterior  superior  dental  nerves  are  given  off  in 
the  infra-orbital  canal  in  the  floor  of  the  orbit  and  enter  special  canals 
in  the  anterior  wall  of  the  antrum. 

Hence,  at  the  spot  illustrated  in  Fig.  96,  we  meet  all  superior  dental 
nerves  united  in  the  trunk  of  the  infra-orbital  nerve.  The  road  to  this 
spot  is  extremely  simple.  In  the  posterior  upper  corner  of  the  ves- 
tibule of  the  mouth,  laterally  of  the  upper  molars,  we  palpate  the 
inferior  border  of  the  maxillary  tuberosity,  above  which,  at  a  dis- 
tance of  from  2  to  2.5  cm.,  the  desired  point  is  reached,  as  illustrated 
by  the  needle  shown  in  Fig.  96, 


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a 

•a 

o 
a 
o 
H 


CONDUCTIVE  ANESTHESIA  203 

The  question  now  arises,  What  tissues  are  to  be  punctured,  and 
what  precautions  are  necessary? 

After  the  needle  has  passed  through  the  mucosa  and  the  thin  fibers 
of  the  buccinator  muscle,  it  encounters  only  loose  connective  tissue. 
Fibers  of  the  external  pterygoid  muscle  at  the  margin  of  the  infra- 
orbital fissure  are  avoided  by  keeping  the  needle  in  close  touch  with 
the  bone.  Some  hesitancy  may  be  entertained  in  regard  to  the  internal 
maxillary  artery.  To  avoid  possible  trouble,  the  rule  is  never  to 
advance  the  needle  more  than  from  2  to  2.5  cm.  upward  and  backward  .(.i/i/L.' 
from  the  mucosa.  '  ',1 " 

In  conductive  anesthesia  in  the  mandible  and  the  superior  dental  ^' 
nerves  there   is  a  possibility  of  injuring  a  bloodvessel  and  producing 
a  hematoma.     This  danger  is  minimized,  however,  if  an  unnecessarily 
deep  advancement  of  the  needle  is  avoided;  it  is  entirely  eliminated 
if  needles  and  hubs  of  suitable  length  are  used. 

Fig.  97 


/->' 


Position  of  the  needle  for  injection  at  the  maxillary  tuberosity.     Needle  yellow. 

Injection  at  the  Maxillary  Tuberosity. — The  Maxillary  Tuberosity. 
-Behind    the   zygomatic   i)rocess   and   above   the   root  apices  of   the 


204  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Upper  molars,  numerous  foramina  are  found,  through  which  stout 
nerve  branches,  the  posterior  superior  dental  nerves,  enter  the  maxilla, 
after  having  run  for  a  short  distance  with  the  main  trunk,  the  superior 
maxillary  or  infra-orbital  nerve,  on  the  bony  surface  of  the  tuberosity 
(see  Figs.  52,  55,  and  56).  These  nerves  supply  the  three  molars  with 
sensory  filaments,  and  must  therefore  be  blocked  in  order  to  obtain 
anesthesia  of  these  teeth  (see  Fig.  62). 

Technique  of  Injection. — The  injection  is  made  at  the  inferior 
portion  of  the  maxillary  tuberosity  by  infiltrating  the  thin  anterior 
wall  of  the  antrum  and  the  nerve  filaments  passing  through  it  to  the 
molars   in   the   following   manner: 

Fig.  98 


Position  of  needle  for  injection  in  mucous  anesthesia  of  upper  first  molar.     Needle  yellow. 
a,  buccal  injection,  b,  palatal  injection. 

In  the  half-open  mouth  the  zygomatic  process  is  palpated,  its 
prominent  border  fixed  with  the  index  finger,  the  lip  drawn  upward, 
and  the  long  needle  No.  17  c,  mounted  upon  the  syringe  with  hub  B, 
is  introduced  high  up  in  the  reflection  of  the  mucous  membrane  at  an 


CONDUCTIVE  ANESTHESIA 


205 


acute  angle  to  the  bony  surface  and  somewhat  away  from  the  bone 
(see  Fig.  97).  The  needle  is  then  advanced  with  a  slight  backward 
and  upward  inclination  (see  Fig.  78,  red  arrow  No.  6),  holding  the 
syringe  away  from  the  maxilla,  but  keeping  the  needle  as  close  as 
possible  to  the  slightly  convex  tuberosity  (see  Fig.  97).  As  soon  as 
the  needle,  which  has  a  length  of  42  mm.,  has  been  inserted  in  the 
mucosa,  about  i  c.c.  of  the  solution  is  gradually  discharged  while 
advancing  the  needle  into  the  tissues  to  its  full  length.  Mucous 
anesthesia  buccally  is  unnecessary. 

Fig.  99 


Conductive  anesthesia  by  way  of  infra-orbital  foramsn. 


Palatally,  an  injection  into  the  mucosa,  as  described  on  page  187, 
is  made  at  the  posterior  palatine  foramen  (see  Figs.  85  and  87).    Within 


206  TECHNIQUE  OF  LOCAL  ANESTHESIA 

ten  minutes,  as  a  rule,  complete  anesthesia  of  the  three  upper  molars 
ensues. 

Infra-orbital  Injection. — The  Infra-orbital  Foramen. — The  anterior 
region  of  the  maxilla  is  dominated  by  an  easily  reached  nerve  plexus, 
the  anterior  superior  deittal  nerves  (see  Figs.  52,  56,  61,  and  62).  These 
are  given  oiT  from  the  superior  maxillary  or  infra-orbital  nerve  just 
before  its  exit  from  the  infra-orbital  foramen,  and,  entering  a  special 
canal  in  the  anterior  wall  of  the  antrum,  divide  into  a  series  of  branches 
which  supply  the  canine  and  incisor  teeth  (see  Figs.  52  and  56).  In 
acute  periostitis  or  abscess,  injection  at  the  root  apices  of  these  teeth 
is  contra-indicated,  as  it  involves  a  risk  of  sepsis.  In  many  cases 
injection  in  the  canine  fossa  produces  a  satisfactory  anesthesia;  usually 
it  is  desirable  to  infiltrate  both  sides. 

Technique  of  Infra-orbital  Injection. — The  inferior  border  of  the 
orbit,  below  which  the  anterior  orifice  of  the  infra-orbital  foramen 
is  situated,  is  palpated,  and  the  tissue  overlying  the  foramen  is  com- 
pressed with  the  thumb  of  the  left  hand,  at  the  same  time  drawing 
the  lip  upward  and  away  from  the  gum  with  the  third  finger  (see 
Fig.  99).  The  infra-orbital  foramen  is  found  0.5  cm.  below  the  lower 
border  of  the  orbit,  and  almost  exactly  above  the  first  bicuspid  (see 
Figs.  52,  56,  and  78).  The  needle  is  inserted  in  the  reflection  of  the 
mucous  membrane  slightly  posteriorly  to  the  root  apex  of  the  canine, 
and  close  to  the  lip  muscles,  somewhat  away  from  the  maxilla,  and 
advanced  obliquely  upward  and  slightly  backward.  As  soon  as  the 
long  needle  No.  17  c,  which  is  mounted  with  the  hub  C  (see  Fig.  100), 
is  felt  below  the  compressing  finger  tip,  from  0.5  to  i  c.c.  of  the 
solution  is  injected.  After  the  injection,  massage  is  applied  to  good 
advantage. 

This  form  of  injection  requires  a  certain  amount  of  pressure  to 
force  the  solution  through  the  foramen,  since  not  the  nerve  trunks 
which  emerge  therefrom  but  those  situated  more  deeply,  viz.,  the 
anterior  superior  dental  nerves,  are  to  be  anesthetized.  This  method 
is  not  conductive  anesthesia  proper,  since  the  solution  is  intended  to 
exert  its  effect  in  the  fundus  of  the  canal. 

This  method   is  indicated  only  in  cases  of  acute  abscess  and  in 


CONDUCTIVE  ANESTHESIA 


207 


major  operations,  such  as  resection,  when  injection  in  the  infra-orbital 
foramina  on  either  side  is  frequently  called  for.  In  simple  cases,  injec- 
tion above  the  root  apex  of  the  canine  (see  Fig.  8i)  insures  complete 


Fig.  100 


Syringe  mounted  with_hub  C  and  needle  No.  17  c  for  injection  at  infra-orbital  foramen  and 

mandibular  foramen. 

success;  this  injection,  moreover,  is  easier  to  execute,  and  invariably 
and  promptly  effective.  The  needle  is  inserted  at  the  root  apex  of 
the  canine,  and  then  advanced  high  up  into  the  canine  fossa,  where 
from  0.5  to  I  c.c.  of  solution  is  deposited. 


208 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Palatally  again  the  injection  is  not  made  in  the  incisive  papilla, 
where  the  insertion  of  the  needle  is  extremely  painful,  but  the  short 
needle  No.  17  a  or  &  is  introduced  parallel  to  the  long  axis  of  the  roots 
of  the  teeth  to  be  anesthetized,  and  from  8  to  10  drops  are  discharged, 
as  described  in  detail  in  the  paragraph  on  mucous  anesthesia  (see 
Figs.  74,  83,  and  85).  Within  ten  minutes  the  anterior  teeth  on  the 
injected  side  are  completely  anesthetized. 


Fig.  ioi 


Position  of  the  syringe  for  injection  at  mandibular  foramen:  ix,  external  oblique  line;  2x,  retro- 
molar  fossa;  3x,  internal  oblique  line;  4,  mandibular  foramen  behind  lingula;  5,  incorrect  position 
of  the  syringe,  parallel  to  the  teeth. 

Injection  at  the  Inferior  Dental  or   Mandibular  Foramen   (Man- 
dibular Injection).— r/ze  Inferior    Dental  or  Mandibular   Foramen. — 


CONDUCTIVE  ANESTHESIA 


209 


The  inferior  dental  or  mandibular  foramen,  situated  in  the  internal 
surface  of  the  ascending  ramus,  permits  the  passage  of  the  inferior 
dental  nerve,  which,  with  the  inferior  dental  artery,  passes  forward 
within  the  dental  canal  in  the  mandible  as  far  as  the  mental  foramen, 
where  it  divides  into  two  terminal  branches,  incisor  and  mental.  In 
the  technique  of  injection  at  the  mandibular  foramen,  certain  impor- 
tant anatomic  features  must  be  duly  considered,  and  for  this  reason 
a  few  topographic  details  will  be  briefly  described. 


Fig.  I 02 


Temporal  M. 


External  pterycfoid  M. 


Genio-glossus  M.   /—^ 
Genio-hyoid  M.  '  '■"''' 


Internal  ptery- 
goid M. 


Digastric  M.      Mylo-hyoid  M. 
Origins  and  insertions  of  muscles  upon  inner  surface  of  the  mandible.     (From  Rauber  and  Kopsch.) 


The  body  of  the  mandible  is  not  continuous  in  a  horizontal  straight 
line  with  the  ascending  ramus  but  presents  a  lateral  deviation  at  the 
angle,  so  that  the  internal  surface  of  the  ascending  ramus  is  not  parallel 
with  the  lingual  surface  of  the  body  of  the  jaw  (see  Figs.  40,  88,  and 
93),  The  rami  spread  posteriorly  (see  Figs.  42,  43,  88,  and  loi);  there- 
fore, if  the  vicinity  of  the  mandibular  foramen  is  to  be  reached,  we 
must  never  advance  posteriorly  parallel  with  the  dental  arch  (see 
Figs.  loi  and  102),  but  parallel  with  the  internal  surface  of  the  ramus, 
and  at  an  acute  angle  to  the  dental  arch  (see  Figs.  42  and  loi).  If  the 
direction  of  the  ascending  ramus  is  projected  anteriorly,  the  line  of 
projection  will  intersect  the  opposite  side  of  the  mandible  between 
the  canine  and  bicuspid  (see  Figs.  42,  43,  and  lOi).    Hence,  in  order 

14 


210 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


to  reach  the  vicinity  of  the  inferior  dental  foramen,  the  syringe  must 
come  to  he  over  the  contact  of  the  canine  and  bicuspid  of  the  opposite 
side  (see  Figs.  42  and  loi).  This  valuable  landmark  enables  one  to 
reach  with  accuracy  the  mandibular  sulcus  occupied  by  loose  connec- 
tive tissue,  which  has  a  great  avidity  for  the  anesthetic  solution  (see 
Fig.  103). 

Fig.  103 


Occipito-frontal  M 
Aponeurosis 


Temporal  fascia 


Temporal  M 


Zygomaiic  a)  ch 


Parotid  gland 


Masseter  M 


External  pterygoid  M. 

:jj  Lateral  plate  of  ptery- 

goid-  process 
Adipose  tissue 

Internal  pterygoid  M. 
Mandible 


Frontal  section  through  temporal  region.  The  black  line  indicates  the  aponeurosis,  the  blue  line 
the  periosteum  and  temporal  fascia.  (From  Merkel.)  At  the  mandibular  foramen  a  mass  of  adipose 
tissue  is  observed  which  offers  no  resistance  to  the  advance  of  the  needle.     {Mandibular  sulcus.) 

Topography  of  the  Inferior  Dental  or  Mandibular  Nerve. — Starting 
with  the  conditions  as  they  present  themselves  in  the  living,  we  shall 
first  study  the  diagram  in  Fig.  104.     The  posterior  limit  of  the  dental 


CONDUCTIVE  ANESTHESIA 


211 


arch  is  marked  by  the  upper  and  lower  right  third  molars.  The  lateral 
boundary  of  the  isthmus  of  the  fauces  is  indicated  at  a  (anterior  pillar 
of  the  fauces).     Laterally  we  note,   ascending  from  the  lower  third 


■Maxillary  tuberosity 


A      d\  \  \\    I 


Diagram  showing  the  mucous  folds  in  the  region  of  the  retromolar  triangle. 

Fig.  105 


View  into  the  oral  cavity,  with  point  of  insertion  of  the  needle  for  mandibular  anesthesia  (white 
spot).     The  point  of  insertion  lies  about  i  cm.  above,  and  laterally  of,  the  last  molar. 

molar,  a  well-defined  mucous  fold  h,  which  may  be  fittingly  called 
the  molar  fold.  At  ex  the  spot  is  marked  where  the  needle  is  to  be 
inserted  for  mandibular  injection.  F  indicates  the  palpating  finger, 
which  is  in  contact  with  the  needle-point  and  the  ascending  ramus. 


212 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Fig.   105  is  a  photograph  of  this  region  in  the  Hving.     Across  the 
dorsum  of  the  tongue  we  look  into  the  isthmus  of  the  fauces,   the 


Frenum  lahii  superioris 
,  Gingiva 


Upper  lip 
..  -  Vpper  dental  arch 

^^--    Hard  palate 

^-  Soft  palate 

Uvula 

Anterior  pillar 

Posterior  pillar 
Tonsil 


^Point  of  insertion  of 
needle  in  retromolar 
fossa 

~^^  Isthmus 


^  Toiiyae 
Cut  portion  of  cheek 

Lower  dental  arch 


Points  for  in- 
jection at  men- 
tal foramen 


Gingiva 
^Frenum  labii  inferioris 
Lower  lip 


Oral  cavity  cut  widely  open.  The  dotted  red  line  indicates  the  correct  position  of  the  syringe 
for  mandibular  anesthesia.  The  red  arrows  at  the  anterior  portion  of  the  mandible  indicate  the 
points  of  insertion  of  the  needle  in  the  reflection  of  mucous  membrane  for  injection  at  the  mental 
foramen.     (After  Spalteholz.) 

anterior  and  lateral  boundary  of  which,  viz.,  the  anterior  pillar  of  the 
fauces,  appears  as  a  small  fold.  Immediately  laterally  and  slightly 
anteriorly,  the  broader  and  bulkier  molar  fold  is  plainly  seen.     At  its 


CONDUCTIVE  ANESTHESIA 


213 


anterior  border  a  white   point   marks   the  place  of   insertion  of   the 
needle  for  mandibular  anesthesia  (see  also  Fig.  io6). 


Fig.   107 


—  Incisor 


rvuJa 

Tonsil 

Posterior  pillar  offmiees 

Anterior  pillar  of  fauces 


Section  made  close  to  the  ascending  ramus  along  which  the  needle  is  to  be  advanced.     (Gasser.) 

These  landmarks  are  all  that  is  to  be  recognized  with  the  eye  by 
way  of  orientation.  The  folds  vary  a  great  deal  in  appearance,  least 
of  them  the  anterior  pillar  of  the  fauces,  so  that,  in  obscure  cases,  this 
furnishes  a  valuable  guide.  A  very  important  indication  for  finding 
the  place  of  injection  is  furnished  by  the  plainly  palpable  external  ridge 
of  the  ascending  ramus,  which  lies  directly  anteriorly  of  the  place  of 
injection.  After  this  spot  has  been  located  correctly,  the  needle  is 
simply  advanced  upon  the  posterior  surface  of  the  ascending  ramus. 


214  TECHNIQUE  OF  LOCAL  ANESTHESIA 

Fig.  107  shows  an  anatomic  preparation. 

The  right  side  of  the  oral  cavity  is  exposed  by  median  section. 
The  sHghtly  distorted  tongue  is  deflected  downward.  The  picture  is 
best  studied  by  beginning  from  the  tonsil  which  is  situated  between 
the  anterior  and  posterior  pillars  of  the  fauces.  In  front  of  the 
latter  the  molar  fold  is  very  clearly  seen  extending  from  the  last 
lower  molar  palatally  toward  the  corresponding  upper  tooth.  Ante- 
riorly to  this  fold,  a  long  incision  is  made  through  the  place  for  the 
insertion  of  the  needle  as  indicated  in  Fig.  105,  exposing  the  struc- 
tures illustrated  in  Fig.  108,  which  represents  the  same  side  in  the 
same  specimen.  The  parts  surrounding  the  prepared  area  are  indi- 
cated diagrammatically.  The  incision  into  the  mucosa  has  been 
widely  drawn  apart,  so  that  the  way  to  the  very  spot  where  the 
injection  is  made  is  plainly  seen.  Together  with  the  mucosa,  the 
anterior  fibers  of  the  buccinator  muscle,  which  in  this  locality  is  thin 
and  therefore  not  noticeable,  is  cut  through,  affording  a  view  into 
the  anterior  part  of  the  space  termed  pterygoid  fissure  or  pterygo- 
maiidibiilar  space. 

The  inner  surface  of  the  mandible  with  the  mandibular  foramen, 
through  which  the  mandibular  nerve  enters  the  mandibular  canal, 
is  clearly  shown.  In  front  we  note  the  tendon  of  the  temporal  muscle 
running  along  the  anterior  border  of  the  ascending  ramus;  in  back  the 
anterior  portion  of  the  internal  pterygoid  muscle. 

Before  entering  the  mandibular  canal  the  mandibular  nerve  gives 
off  two  small  branches:  one  anterior,  supplying  the  mucosa  at  the 
posterior  teeth,  one  posterior,  or  mylohyoid  nerve. 

The  lingual  nerve  is  seen  slightly  retracted;  still,  its  situation  in 
close  proximity  to  the  mandibular  nerve  is  apparent.  The  details  of 
the  relative  positions  of  these  two  nerves  are  seen  in  the  subsequent 
illustrations.  A  small  quantity  of  loose  connective  tissue,  which 
posteriorly  assumes  a  more  adipose  character,  has  been  removed 
from  the  area  under  discussion. 

Figs.  57  and  58,  w^hich  appear  on  pages  164  and  165,  give  a  general 
view  of  the  course  of  the  mandibular  and  lingual  nerves.  In  the  anterior 
view  in  Fig.   57  a  portion  of   the  ascending   ramus  is   removed    and 


CONDUCTIVE  ANESTHESIA 


215 


the  mandibular  canal  is  laid  open.  Between  the  two  pterygoid 
muscles  which  form  the  pterygoid  fissure  the  lingual  nerve  runs 
forward  to  the  floor  of  the  mouth,  the  mandibular  nerve  downward 
into  the  body  of  the  mandible;  anteriorly  the  mandibular  nerve  is 
seen  emerging  from  the  mental  foramen. 


Fig.  io8 


Temporal  M. 
Internal  pterygoid  M. 
Inferior  dental  N. 
Lingual  N. 


Hook  for  retracting 
lingual  N. 

Mandibular  foramen 


View  into  the  mandibular  sulcus.     (Gasser.) 

Fig.  58  represents  a  postero-internal  view;  the  tongue  is  deflected 
inward.  By  removing  the  internal  pterygoid  muscle  the  course  of 
the   mandibular  nerve   to   the   mandibular  foramen   is   exposed.     At 


216  TECHNIQUE  OF  LOCAL  ANESTHESIA 

the  same  time  we  note  the  mylohyoid  nerve;  the  distribution  in  the 
tongue  and  floor  of  the  mouth  of  the  lingual  nerve  with  its  sub- 
maxillary ganghon;  the  hypoglossal  nerve  ascending  from  below;  the 
submaxillary  gland  with  its  duct,  and  the  sublingual  gland. 

To  insure  an  accurate  topographic  orientation,  three  sections 
through  the  mandibular  region  at  the  ascending  ramus  are  repro- 
duced (see  Plates  I  and  II,  and  Fig.  109).  Plates  I  and  II  are  vertical 
microscopic  sections,  Fig.  109  is  a  horizontal  frozen  section  through 
infant  heads. 

In  Plate  I  the  section  goes  through  the  posterior  portion  of  the 
ascending  ramus,  past  the  anterior  border  of  the  condyloid  process. 
The  bloodvessels  have  been  injected  to  facilitate  the  comprehension 
of  their  arrangement;  the  nerves  are  marked  in  yellow.  Of  special 
interest  is  the  space  between  the  two  pterygoid  muscles  on  the  internal 
surface  of  the  mandible.  In  this  space  are  seen  the  internal  maxillary 
artery  and  branches  thereof,  the  mandibular  nerve  and  the  lingual 
nerve.  It  is  important  to  note  that  in  the  posterior  part  of  the 
pterygomandibular  space  these  parts  are  embedded  in  loose,  partly 
adipose  connective  tissue,  and  that  this  space,  which  is  so  important  in 
conductive  anesthesia,  broadens  here  considerably.  This  extension  of 
interstitial  tissue,  as  may  be  seen  in  Fig.  no,  is  situated  between  the 
two  pterygoid  muscles,  and  is  the  greater  the  more  closely  we  approach 
the  posterior  border  of  the  ascending  ramus.  The  mandibular  nerve 
(n.  alveolar  inf.  in  Plate  I),  presents  a  slight  curvature  anteriorly 
as  it  is  about  to  enter  the  mandibular  canal.  The  proximity  of  the 
internal  maxillary  artery  cautions  us  not  to  advance  the  needle  too 
deeply  into  this  space. 

Most  instructive  is  a  comparison  with  Plate  II,  in  which  the 
section  is  made  more  anteriorly  through  the  ascending  ramus  directly 
through  the  mandibular  foramen.  The  lingula  appears  as  a  marked 
projection  covering  the  entrance  to  the  mandibular  canal  and  pro- 
tecting the  mandibular  nerve. 

The  pterygomandibular  space  here  is  considerably  narrower, 
owing  to  the  internal  pterygoid  muscle  being  in  closer  contact  with 
the  mandible.     From  the  foregoing  it  appears  that,  in  order  to  reach 


Fig,  109 


Parotid  gland- 
Lingual  N.. 
Mandibular  N. 
Internal  pterygoid  N. 

Dental  ridge 
Masseter  M. 


'^—Internal  pterygoid  M. 


Mandibular  N. 
Mandible 
Masseter  M. 


Dental  ridge 


Horizontal  frozen  section  through  mandibular  foramen  in  infant  head.     (Gasser.) 


Fischer, Local  Anesthesia. 


buccinator. 


a .  and  vrnaoM. 


-plixwyna! 


-velum,  pal. 
_  «.  UngiiaUs 
' — n. alveolar,  inf. 

tonsil 


'—TTumdibula 
-m^pterygoicl.  int. 


gl.subma.xill. 


'^^i'^^dM 


Vertical    Microscopic   Section    through    Posterior  Portion  of  Ascending 

Ramus  in   Infant   Head. 


Paul  Schmdier .Leipzig,  gez.u.lifh. 


I 


Plate  I.II. 


m.ptercjoid.exf 
ri.buccinalor- 

gl.-pcirotis 


n.Ungualis- 

it.atveolar.tnf 

lingula 

for.mandibidaer- 

mcauUbula   - 

m.  mass  ef fit:    — 

m.pteryq.mt—  - 


yl.submaaHl. 

gl.  sublinff. 

Vertical    Microscopic  Section  through    Mandibular  Foramen 

in  Infant  Head. 


KunsTAnsrAtT  n.F  juirt,  Leipzig. 


CONDUCTIVE  ANESTHESIA 


217 


the  mandibular  nerve,  the  needle  must  be  kept  in  close  contact  with 
the  bone,  and  that  the  conditions  are  more  favorable  about  the  middle 
of  the  ascending  ramus  than  farther  below  (see  Fig.  104).  Further- 
more, it  is  evident  that  the  mandibular  nerve  cannot  be  reached  in 
the  mandibular  foramen,  because  it  is  safely  covered  by  the  lingula, 
but  before  it  reaches  the  foramen,  viz.,  in  the  pterygomandibular  space 
where  infiltration  is  greatly  favored  by  the  loose  connective  tissue 
investing  the  nerve. 


Fig.  1 10 


External  auditory 
meatus 


Spheno-mandih  idar 
ligament 


Lingual  nerve 


Internal  pterygoid 

muscle 
External  pterygoid 

muscle 


Mandibular  nerve 
Mandibular  foramen 


The  sphenomandibular  ligament  is  inserted  at  the  lingula,  which  it  covers  completely.     (Henle. 


In  ^ Fig.  no  the  manner  in  which  the  lingula  is  covered  by  the 
pterygomandibular  ligament  is  beautifully  shown.  This  ligament  is 
of  great  advantage  for  the  management  of  the  needle  in  injecting, 
because  it  effectually  protects  the  muscles. 


218 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


In  order  to  determine  the  local  relationships  of  the  parts,  it  is 
most  desirable  to  compare  two  sections  made  perpendicularly  to 
one  another,  as  one  section  merely  shows  the  arrangement  of  the 
parts  in  one  plane.     For  this  reason.  Fig.  109  has  been  inserted,  which 


Fig.  Ill 


Pterygoid   muscles,  viewed  from   behind,  and  posterior  portion   of  the  ascending  ramus.      The 
mandibular  sulcus  is  open  posteriorly  and  filled  with  loose  connective  tissue.     (After  Testut.) 

is  a  horizontal  section  through  the  same  region.  The  section  is  made 
through  the  commissures  of  the  lips  anteroposteriorly  in  a  slightly 
ascending  plane,  so  as  to  go  through  about  the  middle  of  the  ascend- 
ing ramus.      By  a  fortunate  chance,  the  section    passed  through  the 


CONDUCTIVE  ANESTHESIA  219 

mandible  at  slightly  different  levels,  on  the  left  side  somewhat  deeper 
and  directly  through  the  orifice  of  the  mandibular  foramen,  on  the 
right  side  a  little  above  that  orifice. 

The  parts  are  recognized  by  the  position  of  the  tongue,  with  the 
intersected  soft  palate  and  the  lumen  of  the  pharynx.  On  each 
side  we  note  the  mandible  with  the  two  projections  at  the  anterior 
border  of  the  ascending  ramus,  the  point  of  insertion  of  the  temporal 
muscle  and  the  buccinator  crest;  on  the  outer  side  the  masseter  muscle; 
on  the  inner  the  internal  pterygoid  muscle;  back  of  the  mandible 
the  parotid  gland. 

By  comparing  the  two  sides  it  is  again  seen  that  in  the  anterior 
portion  of  the  mandible  (left  side  of  Fig.  109),  the  passage  of  the  needle 
is  narrowed  by  the  closeness  of  the  internal  pterygoid  muscle  to  the 
bone,  while  a  little  farther  posteriorly  and  above  (right  side  of  Fig. 
109)  the  road  is  free,  because  the  muscle  lies  farther  away  from  the 
bone,  leaving  a  broad  space  occupied  by  adipose  connective  tissue 
in  which  the  mandibular  nerve  is  embedded  before  its  entrance  into 
the  mandibular  foramen;  this  space  is  the  correct  place  for  infiltration. 

In  addition,  Plates  I  and  II  and  Fig.  109  give  a  clear  idea  of  the 
local  relationship  of  the  lingual  nerve  to  the  mandibular  nerve  in  the 
pterygomandibular  space.  The  lingual  nerve  runs  a  little  more 
mesially,  viz.,  at  a  greater  distance  from  the  bone,  still  closely  enough  to 
render  it  highly  probable  that  both  nerves  are  reached  by  infiltration, 
though  the  mandibular  nerve  will  be  affected  more  directly. 

Technique  of  Injection  for  Mandibular  Anesthesia. — In  the  tech- 
nique of  mandibular  anesthesia  the  following  preliminary  observations 
are  important: 

In  the  widely  opened  mouth  the  mucous  folds  which,  as  we  have 
seen,  are  of  such  vital  importance  for  a  successful  injection,  are  not 
recognized  at  first  glance.  In  front  of  the  tonsil  we  note  a  well-defined 
fold,  the  anterior  pillar  of  the  fauces  descending  from  the  soft  palate. 
Mesially  and  anteriorly  another  fold  is  seen  running  in  the  direction 
of  the  dental  arch.  Starting  on  the  inner  lingual  side  the  internal 
oblique  line,  then  the  external  oblique  line,  are  palpated  and  the  tip  of 
the  finger  is  firmly  fixed  in  the  bony  groove  between  these  two  lines. 


220 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


whereupon  a  groove  or  depression  in  the  mucous  membrane  becomes 
visible.  This  corresponds  to  the  underlying  trigonum  retromolare 
or  retromolar  triangle,  so  termed  by  Braun.  Converging  with  the 
fold  c,  the  fold  b  runs  downward;  it  is  between  b  and  c,  yet  more 
closely  to  c,  that  the  needle  must  be  inserted  for  mandibular  anesthesia 
(see  Fig.  104). 

Fig.  112 


Position  of  syringe  for  injection  in  mandibular  foramen  and  palpation  of  retromolar  triangle. 
The  syringe  is  held  like  a  penholder. 


The  patient  is  requested  to  hold  the  head  straight  and  to  open 
the  mouth  wide,  and  with  the  index  finger  of  the  left  or  free  hand 
the  anterior  border  of  the  base  of  the  ascending  ramus  is  palpated. 
Two  very  marked  bony  ridges  are  felt  here,  one  anterior  external,  the 
external  oblique  line,  and  one  posterior  internal,  the  internal  oblique 
line  (see  Figs.  39,  40,  loi  and  104).  Between  these  two  lines,  at 
the  base  of  the  ascending  ramus,  a  shallow  bony  groove  is  situated, 
which  Braun  has  fittingly  called  the  retromolar  fossa,  into  which  the 
palpating  finger  tip  sinks  slightly  (see  Figs.  40  and  104).  Over  this 
bony  fossa  the  mucous  membrane  is  depressed  so  as  to  form  a  sort 


CONDUCTIVE  ANESTHESIA  221 

of  triangle,  the  retromolar  triangle,  so  called.  The  internal  oblique  line 
is  fixed  with  the  finger  nail,  and  the  needle  inserted  close  to  the  nail 
into  the  mucosa  near  to,  yet  not  immediately  at,  the  border  of  the  bone 
(see  Figs.  42  and  lOi).  The  needle  is  then  advanced  horizontally  and 
posteriorly  along  the  inner  surface  of  the  ascending  ramus  on  the  side 
to  be  anesthetized,  while  the  syringe  barrel  rests  on  the  contact  between 
the  canine  and  first  bicuspid  of  the  opposite  side  (see  Figs.  42,  43, 
loi,  112),  until  the  needle  has  disappeared  (see  Fig.  43).  The  needle 
should  be  introduced  into  the  tissue  to  a  depth  of  not  more  than  from 
1.5  to  2  cm.  (see  Figs.  43  and  loi),  lest  it  advance  too  far  beyond 
the  foramen,  and  miss  the  correct  point  for  the  deposition  of  the 
solution.  It  is  best  to  mount  the  syringe  with  the  hub  C  and  the 
needle  No.  17  c  (see  Fig.  100),  so  that  from  3  to  5  mm.  of  the  needle 
remain  visible  outside  of  the  mucosa  (see  Figs.  43  and  loi);  failure 
to  reach  the  correct  point  for  injection  is  then  hardly  to  be  feared. 

The  internal  oblique  line,  which  is  important  in  this  connection, 
varies  greatly  in  different  individuals,  and  is  sometimes  so  strongly 
developed  that  it  causes  difiiculties  in  the  introduction  of  the  needle. 
In  such  cases  the  needle  is  inserted  a  little  more  lingually,  the  syringe 
barrel  being  rested  on  the  contact  between  the  first  and  second  bicus- 
pids or  even  farther  back,  until  one  succeeds  in  passing  this  bony 
ridge  and  reaching  the  inner  surface  of  the  ascending  ramus.  As  the 
needle  advances,  some  solution  is  slowly  discharged,  and  when  the 
depth  is  reached,  the  syringe  is  gently  moved  back  and  forth  so  as 
to  distribute  the  solution  evenly. 

Insertion  of  the  Needle. — The  point  of  insertion  of  the  needle  is 
selected  so  that  the  needle  enters  the  mucous  triangle  about  i  cm. 
above  the  level  of  the  masticating  surfaces  of  the  molars  (see  Figs. 
lOi,  104,  and  105);  in  children  and  young  persons  the  needle  is 
inserted  a  little  farther  posteriorly  and  slightly  lower;  in  old  persons 
higher  up  (see  Fig.  41).  If  the  injection  has  been  executed  correctly, 
mucous  anesthesia  at  the  buccal  gingival  margin  is  superfluous. 

Difficulties. — The  technique  of  this  form  of  injection  offers  some 
difficulties  which,  however,  with  some  practice  are  easily  overcome. 
If  the  correct  level  for  the  insertion  of  the  needle,  viz.,  about  i  cm. 


222  TECHNIQUE  OF  LOCAL  ANESTHESIA 

above  the  masticating  surface  of  the  last  molars,  has  been  found, 
then  the  mandibular  sulcus  is  reached  just  above  the  lingula  (see 
Figs.  43  and  loi).  The  distance  from  the  anterior  margin  of  the 
internal  oblique  line  to  the  posterior  border  of  the  lingula  is  about 
15  mm.,  the  length  of  that  portion  of  the  needle  which  protrudes 
from  the  hub  C  is  25  mm.  (see  Figs.  43  and  loi);  the  needle,  there- 
fore, has  the  correct  length  for  passing  through  the  mucous  layer 
(which  is  not  seen  in  the  illustrations  of  skulls)  and  for  reaching  about 
from  5  to  8  mm.  beyond  the  lingula  (see  Figs.  43  and  loi).  Williger 
has  correctly  emphasized  that  during  the  injection  it  is  best  to  rest 
the  syringe  barrel  on  the  first  bicuspid  or  between  the  canine  and  first 
bicuspid  of  the  opposite  side,  thus  securing  a  certain  support  for  the 
syringe  and  a  guide  for  the  correct  level  for  the  insertion  of  the  needle 
(see  Figs.  42,  43,  loi,  no,  112). 

Management  of  the  Needle. — The  needle  is  first  inserted  to  the 
bone  without  puncturing  the  periosteum.  A  certain  touch  is  soon 
acquired  as  to  whether  the  needle  is  being  advanced  in  the  correct 
direction,  not  pharyngeally,  but  closely  enough  to  the  bone.  If,  in 
case  of  a  very  sharp  angle  of  the  bone,  the  periosteum  is  felt  to  offer 
resistance,  no  matter  how  slight,  the  needle  should  not  be  advanced 
any  farther,  and  under  no  condition  by  force,  else  the  needle  bores 
into  the  periosteum  or  the  bone  and,  if  of  steel,  will  surely  break;  if 
of  iridioplatinum,  will  bend.  It  is  best  to  withdraw  the  needle  care- 
fully for  a  short  distance,  and,  after  slightly  altering  its  direction 
pharyngeally,  to  make  a  new  attempt  at  advancing. 

Injection  of  the  Solution. — The  solution  should  be  discharged  slowly 
and  carefully,  beginning  immediately  after  insertion  of  the  needle,  in 
order  to  anesthetize  simultaneously  the  lingual  nerve,  which  descends 
in  front  of  the  mandibular  nerve  (see  Figs.  57  and  58).  The  bulk  of 
the  solution,  however,  is  deposited  in  the  pterygomandibular  space. 
The  adipose  and  loose  connective  tissues  occupying  this  space  readily 
absorb  the  solution  without  any  pain  to  the  patient.  Infiltration  of 
the  muscles  in  this  region  is  out  of  the  question,  as  has  been  shown 
before;  nor  is  there  any  danger  of  puncturing  the  artery,  which  possesses 
thick  walls,  is  protected  by  the  lingula,  and  has  sufficient  space  to 


CONDUCTIVE  ANESTHESIA 


223 


evade  the  loose  surrounding  tissues  or  the  fundus  of  the  inferior  dental 
canal  (see  Fig.  114).  The  corresponding  vein  is  arranged  around 
the  artery  in  the  form  of  an  intricate  plexus,  and  is  equally  well 
protected.  Moreover,  it  is  extremely  difficult  to  puncture  an  arterial 
wall,  even  to  cut  it  with  a  sharp  knife,  as,  owing  to  its  elasticity,  it 
always  has  the  tendency  to  escape. 

Fig.  113 


Position  of  the  syringe  during  injection  at  the  mandiliular  foramen.    The  finger  of  the  left  hand  rests 

in  the  retromolar  triangle. 


Usually  2  c.c.  of  a  1.5  per  cent,  novocain-suprarenin  solution  are 
injected;  twice  that  quantity,  however,  may  be  used  with  impunity. 

The  injection  in  the  left  ramus  offers  somewhat  greater  difficulties. 
While  on  the  right  side  the  retromolar  triangle  is  palpated  with  the 


224 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


left  hand,  and  the  injection  is  made  with  the  right,  it  is  advisable  to 
use  the  left  hand  for  injection  on  the  left  side,  according  to  Peckert's 
suggestion,  and  to  palpate  and  fix  the  retromolar  triangle  with  the 
right.  Practice  will  soon  determine  for  every  operator  the  technically 
best  method  of  executing  the  injection. 

Fig.  114 


Nerv-es  and  bloodvessels  at  the  mandibular  foramen.     (After  Zuckerkandl  and  Scheff.) 

Effect  of  the  Injection. — About  three  minutes  after  the  injection 
the  patient  perceives  a  slight  tingling  in  the  lip  and  tongue  on  the 
injected  side.  This  tingling  or  pricking  is  the  best  indication  that  the 
injection  has  been  correctly  made.  This  sensation  gradually  increases, 
and  a  certain  numbness  of  the  entire  half  of  the  jaw  ensues,  so  that  the 
contact  of  the  rinsing  glass  with  the  anesthetized  lip  is  no  longer  felt. 
The  patients  have  a  feeling  as  if  the  rim  of  the  glass  had  been  cut 
away  in  semilunar  shape.  The  lip  on  the  anesthetized  side  droops 
slightly,  and  exhibits  symptoms  of  partial  paralysis;  the  patient  usually 
feels  as  if  it  were  greatly  swollen.  A  sensation  of  warmth  is  also  per- 
ceived over  the  entire  anesthetized  area.  Difficulty  in  deglutition  or 
ankylosis  is  absent  if  the  technique  has  been  correct;  its  presence 
indicates  that  the  injection  has  been  made  too  far  pharyngeally  an 


CONDUCTIVE  ANESTHESIA  225 

posteriorly.  The  concomitant  symptoms  persist  for  about  one  hour 
and  then  subside  gradually,  the  former  normal  condition  being  rees- 
tablished after  about  three  hours. 

Anesthesia  of  the  Buccal  Nerve. — From  our  experience  it  seems 
unnecessary  to  anesthetize  the  buccal  nerve. 

Injection  at  the  Mental  Foramen. — With  the  present  perfection  of 
mandibular  anesthesia  the  injection  at  the  mental  foramen,  as  described 
in  the  first  edition,  has  lost  its  significance.  Liberal  use  should  be 
made  of  the  blocking  of  nerve  trunks,  which  does  away  with  any 
additional  injection  on  the  same  side.  The  fact  that  one  correct  injec- 
tion at  the  nerve  trunk  produces  such  perfect  results  constitutes,  in 
our  opinion,  the  enormous  advantage  of  conductive  anesthesia. 

External  Injection  in  Case  of  Ankylosis  or  Infection. — Gadd,  of 
Helsingfors,  has  suggested  a  method  of  external  mandibular  anesthesia 
which  he  has  practised  for  some  time  in  the  surgical  clinic  at  Helsing- 
fors. Insertion  of  the  needle  is  made,  not  as  Peckert  suggested,  from 
the  dorsal  side,  but  at  the  lower  margin  of  the  mandible  between  the 
anterior  border  of  the  masseter  muscle  and  the  angle  of  the  ramus. 
This  method  is  recommended  specially  for  cases  of  ankylosis  and 
serious  infections  of  the  oral  cavity  and  throat,  when  insertion  of  the 
hypodermic  needle  in  the  mucous  membrane  in  the  mouth  would 
involve  the  risk  of  carrying  infectious  material  into  deeper  strata. 
This,  Riethmiiller  writes,^  is  the  only  indication  for  external  man- 
dibular anesthesia.  Generally  a  most  satisfactory  anesthesia  is 
obtained  by  the  conductive  method  inside  the  mouth,  if  the  operator 
has  once  learned  to  master  the  technique.  The  external  method  is 
more  complicated,  uncertain,  painful,  and  formidable  to  the  patient, 
and  its  advocacy  in  any  other  cases  than  those  cited  will  only  tend  to 
complicate  our  technique  and  discourage  practitioners  from  adopting 
conductive  anesthesia. 

1  Dental  Cosmos,  March,  19 14,  p.  385. 


15 


226  TECHNIQUE  OF  LOCAL  ANESTHESIA 


RESUME   OF  THE   CLINICAL   VALUE   OF   CONDUCTIVE 

ANESTHESIA. 

The  topography  presented  in  the  foregoing  furnishes  convincing 
proof  that,  in  the  mandible  as  well  as  in  the  maxilla,  nerve  trunks  can 
be  intercepted  by  injection  at  certain  points  of  their  course,  and  that 
conductive  anesthesia  should  be  the  method  finally  selected  in  most 
dental  operations.  The  practical  simplification  of  the  instrumentarium 
insures  a  simple  technical  execution  of  the  methods  advocated,  viz., 
conductive  anesthesia  of  the  maxilla  by  way  of  the  posterior  palatine 
canal,  and  of  the  mandible  by  way  of  the  mandibular  foramen.  As  the 
injections  are  made  at  a  considerable  distance  from  the  field  of  opera- 
tion a  number  of  disadvantages  are  eliminated  which  in  infiltration  or 
mucous  anesthesia  are  present  more  or  less  manifestly,  such  as  anemia, 
metabolic  disturbances  in  the  tissues,  hence  impaired  tendency  to  heal, 
risk  of  infection,  postoperative  pain,  etc.  The  course  of  all  operations 
performed  under  conductive  anesthesia  is  at  least  as  favorable  as 
that  of  interventions  made  under  general  anesthesia. 

By  the  use  of  the  special  instrumentarium  advocated  all  com- 
plications or  failures  that  might  arise  in  conductive  anesthesia  are 
practically  wholly  eliminated.  The  blunt  needle  can  never  produce  a 
serious  injury  of  important  organs  or  bloodvessels,  but  cautiously 
advances  in  their  vicinity,  pushing  aside  any  bloodvessels  encountered 
in  its  progress.  In  the  maxilla  as  well  as  in  the  mandible  the  needle 
must  pass  only  through  a  thin  fascial  layer,  and  almost  immediately 
after  insertion  encounters  thick  strata  of  interstitial  connective  and 
adipose  tissue.  After  insertion,  the  sharp  trocar  is  immediately  with- 
drawn, and  the  advancing  blunt  needle  is  guided  by  a  well-defined 
osseous  surface,  viz.,  in  the  maxilla  by  the  tuberosity,  in  the  mandible 
by  the  anterior  border  of  the  ascending  ramus  (retromolar  triangle). 

The  finding  of  the  proper  places  for  insertion  of  the  needle  is 
greatly  facilitated  in  both  jaws  by  characteristic  bony  surfaces;  in  the 
maxilla  by  palpation  of  the  malar  bone  posteriorly  to  which  the 
maxillary    tuberosity    is    immediately    reached;    in    the    mandible    by 


RESUME  OF  CLINICAL   VALUE  OF  CONDUCTIVE  ANESTHESIA     227 

palpation  of  the  anterior  border  of  the  ascending  ramus.  The  mucous 
folds  over  the  retromolar  triangle  are  as  unreliable  a  guide  as  is  the 
development  of  the  bony  groove  situated  between  the  two  oblique  lines, 
since  both  these  landmarks  vary  greatly  in  different  individuals,  and 
cannot  be  used  as  never-failing  indicators.  In  every  case  the  pal- 
pating finger  must  fix  the  anterior  border  of  the  ascending  ramus,  sink 
in  the  bony  groove,  if  it  is  present,  and  remain  stationary  for  the 
guidance  of  the  needle  as  it  is  inserted  at  the  inner  border  of  the  bone. 
This  palpating  is  done  with  the  index  finger,  not  with  the  thumb,  as 
Seidel  proposes.  No  other  finger  is  as  suitable  for  palpation  as  the 
index  finger,  which  is  endowed  with  an  extremely  delicate  sense  of 
touch.  Despite  Seidel's  proposed  modifications,  which  in  our  opinion 
merely  complicate  matters,  our  technique  has  not  been  changed;  nor 
can  it  be  changed,  because,  as  Braun  writes,^  "It  is  self-evident." 

The  primary  condition  for  a  successful  and  safe  conductive  anes- 
thesia is  a  suitable  instrumentarium.  After  a  number  of  experiments 
in  ..green  skulls  and  in  patients  it  has  been  ascertained  that  the  tele- 
scoping thick  and  blunt  trocar  needle  is  the  most  suitable.  It  is  slightly 
curved,  and  in  advancing  insures  continuous  contact  with  the  bone. 
Being  blunt,  it  slides  forward  past  the  delicate  tissue  areas  without 
injuring  any  bloodvessels.  If  the  injection  is  started  immediately 
upon  insertion  of  the  needle,  then  the  solution  will  be  safely  and  evenly 
distributed. 

The  perforation  of  muscle  fibers  is  not  a  complicating  factor, 
because  the  clean-cut  lesion  of  the  muscle  invariably  heals  by  first 
intention.  There  is  no  risk  of  infiltrating  the  muscles,  since  the  injec- 
tion is  not  started  until  after  the  muscular  layer  has  been  passed. 
Puncturing  and  advancing  in  the  internal  pterygoid  muscle  is  impossible 
with  this  method  if  the  technical  conditions  are  fulfilled.  It  is  most 
desirable,  of  course,  that  the  correct  technique  be  acquired  by  demon- 
strations in  situ,  because,  as  Braun  remarks,  ''Its  greatest  difficulty 
consists  in  its  description." 

Injection  at  the  Maxillary  Tuberosity. — Injection  at  the  maxillary 
tuberosity,   the  technique  of  which   has  been  described   in  detail  on 

'  Text-book  of  Local  Anesthesia,  third  eihtion,  p.  251. 


228  TECHNIQUE  OF  LOCAL  ANESTHESIA 

pages  203  to  205,  renders  any  additional  buccal  or  lingual  injections 
superfluous,  and  produces  complete  anesthesia  of  the  molars  and 
bicuspids.  If  anterior  teeth  are  to  be  operated  upon  it  is  best  to 
make  an  injection  at  the  tuberosity  on  either  side;  or  mucous  anes- 
thesia by  way  of  the  canine  fossa  toward  the  anterior  nasal  spine  may 
be  resorted  to. 

Injection  at  the  maxillary  tuberosity,  as  a  rule,  produces  complete 
anesthesia  within  from  six  to  fifteen  minutes;  it  is  tolerated  perfectly 
well,  and  its  execution  is  generally  painless.  It  does  away  entirely 
with  injection  at  the  infra-orbital  foramen,  and  greatly  simplifies 
the  anesthesia  of  the  maxilla. 

Mandibular  Injection. — Injection  at  the  mandibular  foramen,  the 
technique  of  which  has  been  described  in  detail  on  pages  208  to  225, 
renders  any  additional  injection  in  the  vicinity  of  a  tooth  superfluous. 
Mucous  anesthesia,  in  fact,  is  contra-indicated,  as  it  detracts  from 
the  advantages  of  conductive  anesthesia,  viz.,  rapid  wound  healing, 
liberal  hemorrhage,  easy  absorption,  etc.  Our  controls  have  shown 
that  anesthesia  of  the  mandibular  and  lingual  nerves  includes  the 
entire  mucous  covering  of  the  injected  side  of  the  mandible,  in  the 
same  way  as  injection  at  the  maxillary  tuberosity  produces  anesthesia 
of  the  entire  maxillary  half  including  the  mucous  membrane. 

These  two  methods  of  anesthesia  are  extremely  valuable  in  relation 
to  therapeutics,  and  owing  to  their  great  simplicity,  combined  with 
innocuousness,  safety,  and  absence  of  untoward  sequelae,  are  superior 
to  the  method  of  infiltration  of  the  gingivae. 

Principles  of  Conductive  Anesthesia. — i.  Thorough  sterilization 
of  the  mucosa  with  tincture  of  iodin,  thymol-alcohol,  or  one  of  the 
decolorized  preparations  of  iodin. 

2.  Infiltration  of  the  perineurial  tissue. 

3.  Only  one  insertion  of  the  needle. 

4.  The  orifice  of  the  needle  must  always  point  toward  the  bone 
and  advance  along  the  bone. 

5.  The  solution  is  discharged  under  moderate  pressure,  gently 
moving  the  syringe  back  and  forth. 

6.  For  injection  at  the  maxillary  tuberosity  the  malar  process  is. 


EXTENT  OF  LOCAL  ANESTHESIA   IN  THE  MAXILLA  229 

palpated.  The  needle  is  inserted  in  the  mucous  membrane  behind 
the  process,  and  advanced  to  the  convexity  of  the  tuberosity,  thence 
upward  and  slightly  backward  in  the  direction  of  the  temple. 

7.  In  mandibular  anesthesia  the  retromolar  triangle  is  palpated, 
allowing  the  finger  tip  to  rest  therein.  The  needle  is  inserted  i  cm. 
above  the  level  of  the  masticating  surfaces  of  the  molars,  and  at  the 
inner  border  of  the  ascending  ramus;  the  syringe  is  guided  by  the 
canine  and  first  bicuspid  of  the  opposite  side.  The  needle  is  advanced 
backward  and  outward,  in  adults  straight,  in  children  slightly  down- 
ward.    While  injecting,  the  syringe  is  gently  moved  back  and  forth. 

8.  A  waiting  period  of  ten  minutes  in  the  maxilla;  of  twenty  minutes 
in  the  mandible. 

9.  The  patient  should  be  kept  under  observation  after  the  injection. 


EXTENT    OF    LOCAL    ANESTHESIA    IN    THE    MAXILL.E. 

The  action  of  local  anesthetics  in  the  healthy  organism  can  be 
traced  step  by  step,  especially  with  the  aid  of  the  electric  current. 

Completion  of  Anesthesia  in  the  Maxilla. — In  mucous  anesthesia 
of  the  upper  central  incisors  the  sensibility  of  the  pulp  is  notably 
diminished  after  two  minutes;  it  gradually  decreases,  until  after  five 
minutes  complete  anesthesia  is  established.  This  condition  of  com- 
plete anesthesia  usually  lasts  from  twenty  to  twenty-five  minutes.  It 
is  noteworthy  that,  even  during  this  state  of  complete  anesthesia, 
strong  electric  currents  still  exert  an  influence  upon  the  eye,  producing 
a  slight  oscillation  as  well  as  lacrimal  secretion,  owing  to  the  relation- 
ship between  the  first  and  second  divisions  of  the  trigeminal  nerve. 
After  about  seventy  minutes,  counting  from  the  beginning  of  the  injec- 
tion, normal  conditions  were  reestablished  in  the  cases  examined. 

Anesthesia  in  the  Region  of  the  Maxillary  Tuberosity. — After 
injection  at  the  maxillary  tuberosity  and  in  the  posterior  palatine 
foramen,  sensibility  is  reduced  in  all  molars  and  bicuspids  after  two 
minutes;  after  five  minutes  the  canine  also  exhibits  reduced  sensi- 
bility.   After  three  additional  minutes,  the  buccal  mucous  membrane  is 


230  TECHNIQUE  OF  LOCAL  ANESTHESIA 

entirely  insensible,  while  the  lip  seems  still  to  react  normally.  Within 
ten  minutes,  complete  anesthesia  is  established  in  all  molars,  lasting  for 
over  ten  minutes,  then  gradually  subsiding.  The  sensibility  of  the 
bicuspids  and  canines  is  notably  reduced.  Within  from  thirty  to  forty 
minutes  normal  sensibility  is  reestablished  in  every  tooth,  while  the 
mucosa,  especially  in  the  vicinity  of  the  maxillary  tuberosity,  is  still 
completely  anesthetized. 

The  prompt  effect  of  injection  at  the  maxillary  tuberosity  was 
demonstrated  in  a  highly  sensitive  and  seriously  neurotic  woman. 
Anesthesia  of  the  second  upper  bicuspid  with  an  inflamed  pulp  was 
accompanied  by  the  following  symptoms:  After  two  minutes  light 
anesthesia  set  in  in  all  molars  and  bicuspids  of  the  injected  side.  After 
three  minutes  the  teeth,  which  had  been  extremely  sensitive  to  a 
light  current,  tolerated  a  current  of  double;  after  five  minutes,  one  of 
triple  strength.  After  fourteen  minutes  complete  anesthesia  was 
established.  The  pulp  of  the  second  bicuspid  was  amputated  to  the 
root  canals  without  any  pain  whatever.  For  the  sake  of  experiment, 
the  strong  current  was  applied  to  the  amputated  pulp  stumps.  It  was 
surprising  to  note  a  very  faint  reflex.  Nevertheless  the  root  portions 
of  the  pulp  were  immediately  extirpated  without  any  pain  whatever, 
contrary  to  expectation.  The  mechanical  irritation  incidental  to  extir- 
pation of  the  pulp  evidently  produced  no  pain,  while  the  electric 
irritation  was  still  perceived,  presumably  because,  in  contradistinction 
to  the  irritation  from  localized  pressure,  it  was  conveyed  by  the  cells 
to  remote  areas  of  sensation.  After  twenty-six  minutes  the  anesthesia 
began  to  wear  off. 

Anesthesia  in  the  Region  of  the  Infra-orbital  Foramen. — At  the 
infra-orbital  foramen  the  injection  produced  a  pronounced  anes- 
thetization of  the  superficial  mucous  and  muscular  layers,  charac- 
terized by  a  reduction  in  sensibility  within  one  minute.  The  anterior 
teeth  were  completely  anesthetized  after  eleven  minutes,  sensibility 
gradually  returning  after  twenty-five  minutes. 

Mucous  Anesthesia  in  the  Mandible. — The  effect  of  mucous  anes- 
thesia in  the  mandible  appears  to  be  rather  uncertain.  This  form  of 
anesthesia  was  applied  to  a  lower  first  bicuspid  affected  with  pulpitis; 


EXTENT  OF  LOCAL  ANESTHESIA   IN  THE  MAXILLM 


231 


the  sensibility  of  the  pulp  was  not  reduced  notably,  even  after  eight 
minutes.  When  anesthesia  by  way  of  the  mandibular  foramen  was 
subsequently    induced,    within    three    minutes    the    sensibility   of   the 


Fig.  115 


Couducl.  (inesth.  hy  way  vf 
^\mfra-orhital  foramen 


...        ('"itduct.  aw-fsth.  hi/  way  0/ 
^ll*i      iniirlllari/  fuhi'iosif,,' 


7  ManriUmiar  funimen 


Conduct,  (me-stli.  hy  way  of 
mandihidar  foraiUfu 


MitcouH  anexthema 


(oiidnct.  >nii:sfh.  hy  way  of  muluti  fnssa 


Conduct  ire  an  eMhenia 


Diagram  illustrating  the  technique  and  dosage  for  local  injection.  On  the  left,  black  figures 
indicate  technique  and  dosage  for  mucous  anesthesia.  On  the  right,  red  figures  indicate  technique 
and  dosage  for  conductive  anesthesia.  Dosage:  i  =  about  10  drops;  2  =  0.25  c.c;  3  =  0.5  c.c; 
4  =  I  c.c;  5  =  1 .25  c.c;  6  =  1.5  c-c-i  7  =  2  c.c. 


232  TECHNIQUE  OF  LOCAL  ANESTHESIA 

inflamed  pulp  was  considerably  reduced,  and  complete  anesthesia 
ensued  within  fourteen  minutes  from  the  beginning  of  the  experiment. 
Anesthesia  by  Way  of  the  Mandibular  Foramen. — In  another 
case  it  was  observed  that  within  three  minutes  after  injection  at  the 
mandibular  foramen  anesthesia  of  the  corner  of  the  mouth  and  the 
mucosa  of  the  lip  was  established.  After  four  minutes  tingling  in  the 
lip  and  in  the  corresponding  half  of  the  tongue  was  perceived.  The 
tongue  grew  heavier  every  minute,  and  the  numbness  of  the  lip  spread 
to  the  other  side.  After  ten  minutes  the  teeth  on  one  side  of  the  man- 
dible with  the  exception  of  the  second  molar  and  the  canine  were 
insensible,  and  within  twenty-three  minutes  altogether  the  entire 
half  of  the  jaw  was  anesthetized.  Complete  anesthesia  with  all  its 
symptoms  persisted  for  twenty-five  minutes,  after  which  time  it 
gradually  subsided.  The  central  incisors  were  the  first  to  regain 
sensitivity,  and  were  followed  in  rapid  succession  by  the  other  teeth. 
The  tongue  had  become  normal  after  ninety-seven  minutes,  while 
the  mucosa  remained  insensible  even  after  one  hundred  and  twenty- 
five  minutes,  Normal  sensibility  was  not  reestablished  until  three 
hours  after  injection. 


TABLES    FOR    INJECTION    ANESTHESIA. 

In  order  to  avoid  repetitions  such  as  histories  of  practical  cases 
would  entail,  yet  in  order  to  offer  a  practical  working  scheme  for  the 
application  of  the  methods  described,  tables  are  here  presented  which 
indicate  the  method  of  injection  best  suited  for  each  tooth.  The 
special  requirements  of  a  case  may,  of  course,  call  for  modifications 
of  these  tables,  which  are  intended  as  a  general  guide  to  those  who 
wish  to  become  experts  in  this  somewhat  difficult  technique. 

Periods  of  Waiting. — The  period  of  waiting  in  the  cases  Nos.  i  to  4 
and  9  to  10  is  about  ten  minutes;  in  Nos.  5  to  8,  fifteen  minutes;  in 
Nos.  II  to  16,  twenty  minutes.  In  Nos.  9  to  16  no  injection  lingually 
is  required.  Modifications  or  combinations  for  the  anesthetization  of 
several  teeth  on  one  side  can  easily  be  deduced  from  these  tables. 


TABLES  FOR  INJECTION  ANESTHESIA 


23J 


Teeth. 
I.  UPPER. 


Technique  of  injection  employed. 


(o)  In  simple  cases. 


(6)  In  cases  complicated 

by  periostitis,  parulis, 

abscess,  etc. 


Mountings 

of 

syringe. 


Quantity  of  solution. 


In  labial  or 

buccal 
injections. 


In  palatal 
or  lingual 
injections. 


I.  Central 
incisors. 


2.  Lateral 
incisors. 


(^'■^1      3.  Canines. 


4.  First 
bicuspids. 


5.  Second 
bicuspids. 


6.  First 
molars. 

7.  Second 
molars. 

8.  Third 
molars. 


Needle  inserted  at  mid- 
dle of  root  of  lateral, 
and  directed  to  root 
apex  of  central.  Pala- 
tally,  injection  at  cen- 
tral. 


Needle  inserted  at  mid- 
dle of  root  of  canine, 
and  directed  to  root 
apex  of  lateral.  Pala- 
tally,  injection  at 
lateral. 


Needle  inserted  at  root 
apex  of  canine,  where 
solution  is  deposited. 
Palatally,  injection  at 
canine. 

Needle  inserted  at  mid- 
dle of  root  of  canine, 
and  directed  to  root 
apex  of  first  bicuspid. 
Palatally,  injection  at 
first  bicuspid.  Or  in- 
jection at  maxillary 
tuberosity. 

Needle  inserted  at  mid- 
dle of  root  of  first  bi- 
cuspid and  directed  to 
root  of  second  bicuspid. 
Palatally,  injection  at 
second  bicuspid.  Or 
injection  at  maxillary 
tuberosity. 

Injection  at  maxillary 
tuberosity. 

Injection  at  maxillary 
tuberosity. 

Injection  at  maxillary 
tuberosity. 


Needle  inserted  at  mid- 
dle of  roots  of  canine 
of  same,  and  central  of 
opposite  side,  whose 
root  apices  are  infil- 
trated with  solution ; 
palatally,  injections  at 
lateral  of  same,  and 
central  of  opposite  side. 
Or  conductive  anes- 
thesia at  infra-orbital 
foramen,  and  mucous 
anesthesia  at  central 
of  opposite  side,  pala- 
tally. 

Needle  inserted  back  of 
root  apex  of  canine, 
where  solution  is  de- 
posited; same  proced- 
ure at  root  apex  of 
central.  Palatally,  in- 
jection at  lateral,  or  at 
central  and  canine. 

Conductive  anesthesia 
at  infra-orbital  fora- 
men. Palatally,  injec- 
tion at  canine,  or  first 
bicuspid  and  lateral. 

Injection  at  maxillary 
tuberosity. 


Injection   at  maxillary 
tuberosity. 


Injection   at   maxillary 

tuberosity. 
Injection   at   maxillary 

tuberosity. 
Injection   at   maxillary 

tuberosity. 


Hub  B, 
needle.  No. 
17a. 

For  conduc- 
tive anes- 
t  h  e  s  i  a  , 
needle  No. 
17c. 


As  in  I. 


(a)  As  in  i. 
lb)  Long 
needle  No. 
17c. 

Hub  C  and 
long  needle 
No.  17c,  or 
trocar 
needle. 


As  in  4. 


As  in  4. 
As  in  4. 
As  in  4. 


In  cases 
(a)  0.5  c.c. 
{b)  1 .0  c.c. 


(a)  0.5  c.c. 
{b)  1 .0  c.c. 


{a)  1 .0  c.c. 
lb)  1.5  c.c. 


2  to  4  c.c. 


2  to  4  c.c. 


1.5  to  2.0 
c.c. 

1.5    to   2.0 

c.c. 

1.5    to   2.0 

c.c. 


of  class, 
(a)  0.1  c.c. 
{b)  0.3  c.c. 


(a)  o.  I  c.c. 
(6)  0.3  c.c. 


(a)  0.5  c.c. 
{b)  0.5  c.c. 


No  injection 
palatally 
required. 


234 


TECHNIQUE  OF  LOCAL  ANESTHESIA 


Teeth. 
II.  LOWER. 


Technique  of  injection  employed. 


(a)  ■  In  simple  cases. 


(&)   In  cases  complicated 

by  periostitis,  parulis, 

abscess-  etc. 


Mountings 

of 

syringe. 


Quantity  of  solution. 


In  labial  or 

buccal 
injections. 


In  palatal 
or  lingual 
injections. 


9.  Central 
incisors. 


10.  Lateral 
incisors. 


II.  Canines. 


12.  First 
bicuspids. 


13.  Second 
bicuspids. 

14.  First 
molars. 

15.  Second 
molars. 

16.  Third 
molars. 


Needle  inserted  at  mid- 
dle of  root  of  lateral 
and  directed  to  root 
apex  of  central.  Lin- 
gually,  injection  at 
central. 

Needle  inserted  at  mid- 
dle of  root  of  canine, 
and  directed  to  lateral. 
Lingually,  injection  at 
lateral. 

Needle  inserted  in  re- 
flection of  mucous 
membrane  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Lingually,  injection  at 
canine  or  first  bicuspid, 
or  mandibular  anes- 
thesia. 

Mandibular  anesthesia. 


Needle  inserted  in  re- 
flection of  mucous 
membrane  below  ca- 
nine and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Needle  inserted  in  re- 
flection of  mucous 
membrane  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Needle  inserted  in  re- 
flection of  mucous 
membrane  below  ca- 
nine, and  directed  to 
mental  fossa,  where 
solution  is  deposited. 
Mandibular     anesthe- 


Mandibular  anesthesia. 


(a)  Hub    B 
and  needle 
No.  17a. 
{b)    needle 
No.  17c. 


(a)  0.6  c.c. 

[b)  1 .0  c.c. 


(a)  Hub  B  I  (a)  0.6  c.c. 
and  needle  ,  {b)  i.o  c.c. 
No.  17a. 
{b)  needle 
{  No.  17c. 


(a)  0.25  c.c. 

[b)  0.25  c.c. 


(a)  0.25  c.c, 
{b)  0.25  c.c. 


Hub  C  and 
needle  No. 
17c. 


(a)  1.0  c.c.  '  (a)  0.25  c.c. 
{b)  2,0  c.c.     [b)  0.25  c.c. 

(see  Fig. 

94)- 


Mandibular  anesthesia.  .Mandibular  anesthesia. 
Mandibular  anesthesia.  ; Mandibular  anesthesia. 
Mandibular  anesthesia.  .Mandibular  anesthesia. 


'Mandibular  anesthesia. 


Mandibular  anesthesia. 


Hub  C  and 

needle  No. 

17c,  or  tro- 
car needle. 
Hub  C  and  |  2, 

needle  No. 

17c. 
Hub  C  and  ;  2, 

needle  No. 

17c.  ' 

Hub  C  and    2. 

needle  No. 

17c. 

Hub  C  and  2. 

needle  No.  I 

17c.  I 


2.0  c.c. 


When  indicated,  no  hesitancy  need  be  felt  about  injecting  at  the 
mandibular  foramen  on  each  side  at  one  sitting.  The  results  of  this 
double  injection  are  surprisingly  favorable,  and  no  untoward  sequelae, 
alarming  symptoms  of  paralysis  or  tongue-biting  have  so  far  been 
observed.  In  the  same  way  the  entire  upper  jaw  can  be  anesthetized 
by  injection  at  the  maxillary  tuberosity  on  each  side.  It  is  specially 
in  major  operations  that  conductive  anesthesia  is  most  distinctly 
indicated  and  has  proved  to  be  of  incalculable  value  as  a  substitute 
for  general  anesthesia. 


CONCLUSION  235 


CONCLUSION. 


It  only  remains  to  remind  the  reader  that  the  foregoing  pages 
have  as  their  motive  the  stimulation  of  careful  practical  employment 
of  local  anesthesia;  consequently  we  have  left  untouched  or  have 
merely  grazed  the  surface  of  many  important  matters  of  scientific 
interest  less  immediately  relevant  to  the  main  design  of  these  pages — 
strict  adherence  to  which  has,  happily,  been  rendered  easier  by  the 
fact  that  Braun,  in  his  great  Text-book  on  Local  Anesthesia,  has  dealt 
with  many  of  the  theoretical  problems  in  an  almost  exhaustive  manner, 
so  far  as  our  present  knowledge  extends. 

It  is  hoped  that  our  labor  may  contribute  to  a  general  adoption 
of  local  anesthesia  in  dentistry,  so  that  its  beneficent  aid  may  become 
the  routine  recourse  of  all  dentists.  Notwithstanding  some  recent 
efforts  in  advocacy  of  general  anesthesia  in  dentistry,  that  method 
would  seem  foredoomed  to  ultimate  abandonment  by  our  profession, 
owing  to  the  far  greater  advantages  afforded  by  local  anesthesia  when 
applied  by  skilled  hands.  The  method  by  injection  is  demonstrated  to 
be  equally  as  suitable  for  oral  surgery  as  for  the  less  severe  requirements 
of  conservative  dentistry,  and,  as  employed  today,  is  indicated  very 
decidedly  for  dentinal  anesthesia,  contrary  to  some  contentions  adverse 
to  its  use. 

Success,  however,  in  the  field  of  this  valuable  accessory  to  our 
specialty  must  not  be  expected  from  mere  superficial  study;  for  truly 
satisfactory  results,  especially  facility  in  the  technique  of  actual  injec- 
tion, can  be  acquired  only  by  conscientious  practice.  As  an  encour- 
agement in  patient  efforts  toward  the  acquisition  of  wider  powers, 
let  us  reflect  that  attainment  will  not  only  mean  the  enhanced  con- 
fidence of  our  patients  in  us,  but  we  shall  be  materially  contributing 
to  establish  dentistry  as  a  science  upon  a  plane  which  its  character 
and  importance  demand,  and  to  raise  its  professional  status  in  the 
eyes  of  the  civilized  world. 


I  NDEX. 


Abscess,  acute,  infra-orbital  injection  in,  206 

anesthesia  in,  195 

mucous  anesthesia  in,  179 

in  upper  lateral  incisor,  injection  for,  180 
Abscessed  areas,  peripheral  injection  for,  196 
Acoin,  23,  38 
Accidents,  breaking  of  needle,  loi 

the  operator's  responsibility  in,  32 
Adralgin,  53 
Adrenalin,  24,  48 

effects  of,  on  cocain,  40 
Alcohol-glycerin    solution    for    keeping    syringes 
sterile,  89 

prolonged  anesthesia  due  to,  118 
Alkalies,    untoward    effect    on    novocain- supra- 

renin,  58,  69 
Alveolar  process  in  mandible,  character  of,  153 
in  maxilla,  cancellous  nature  of,  151 
minute  distribution  of  nerves  in,  173 
structure  of,  148 

ridges,  137 
Alveoli,  structure  of,  150 
Alypin,  23,  38 

in  crown  and  bridge  work,  127 

pluglets  for  pressure  anesthesia,  120 
Ampoules,  41,  55 

sterilization  of,  90 
Amyl  nitrite  in  collapse,  103 
Analgesia,  99 

definition  of,  21 
Anamnesis,  30,  108 
Anastomoses  of  nerves,  164 

stimuli  referred  by,  166 
Andolin,  53 

Anemia  of  mucosa,  186 
Anemic  patients,  advantages  of  stasis  bandage 

in,  91 
Aneson,  38 
Anesthesia,  definition  of,  21 

history  of,  21 

local,  effects  of,  131,  133 

in  maxillae,  extent  of,  229 

pressure,  120 
Anesthesin,  23,  38 

Anesthetics,  local,  secret  preparations  of,  44 
Ankylosis,  due  to  faulty  technique,  224 

external  injection  in  case  of,  225 


Anterior  nasal  spine,  137 

palatine  foramen,  142 
Antidotes  in  collapse,  103 
Aqua  destillata,  importance  of  purity  of,  67 

regia  in  pulp  extirpation,  127 
Arsenic  paste  for  devitalization  of  pulps,  106 
Arteriosclerosis,  harmlessness  of  normal  solution 

in,  109 
Artery,  inferior  dental,  202,  209 

internal  carotid,  162 
maxillary,  202,  216 

mandibular,  no  risk  of  puncture,  222 
Ascending  ramus,  143 
Asepsis  in  injecting,  95 
Aspirin  for  postoperative  pain,  105 
Auriculotemporal  nerve,  162 


B 

Bernatzik's  solution,  53 
Bicuspids,  lower,  injection  for,  195 
mucous  injection  for,  191 
upper,  injection  for,  180,  182,  183,  185 
nature  of  bone  in,  140 
nerve  supply  of,  169 
Bloodvessels  at  mandibular  foramen,  224 

nerve  supply  of,  177 
Bone,  differing  character  of,  135,  148 
Bonnighausen's  local  anesthetic  corona,  53 
Bony  surface  of  palate,  189 

structure  of  maxillae,  148 
Bridge  work,  indications  for  local  anesthesia  in, 
127 


Bromural  as  a  sedative,  97 
Buccal  injection  in  maxilla,  183 

nerve,  anesthesia  of,  225 
Buccinator  nerve,  162,  172 


Calcium  salts,  addition  to  novocain-suprarenin 
solution,  62 
antiphlogistic  action  of,  63 
Canal,  infra-orl)ital,  160,  202 

mandibular,  163,  172,  209 
Canaliculated  bone,  135 


238 


INDEX 


Cancellated  bone,  135 
Canine  fossa,  139 

lower,  injection  for,  195 

mucous  injection  for,  192 
upper,  injection  for,  180,  182,  184,  185 
mucous  anesthesia  in  abscess  of,  179 
nerve  supply  of,  167 
Capillaries,  nerve  supply  of,  177 
Carbolic  acid,  local  effects  of,  131 
Caroticotympanic  nerve,  162 
Carotid  artery,  internal,  162 
Catarrh,  nasal,  novocain  in,  129 
Cavity  preparation,  chloral  hydrate  as  a  seda- 
tive in,  124 
under  local  anesthesia,  care  in,  123 
morphin  as  a  sedative  in,  125 
novocain  in,  120 
quinin  as  a  sedative  in,  124 
Central  incisors,  upper,  injection  for,   180,   182, 

188 
Chemical  methods  of  anesthesia,  37 
Children,  bromural  in,  97 

ethyl  chlorid  in,  99 
Chloral  hydrate  as  a  sedative  in  cavity  prepara- 
tion, 124 
Chlorophenol,  for  wound  treatment,  105 
Chorda  tympani  nerve,  162 
Ciliary  ganglion,  158 
nerves,  long,  158 
Cocain,  after-effects  of,  34 

contra-indicated   in    obtunding    hypersensi- 
tive dentin,  123 
contra-indications  to,  41 
dosage  of,  39 

erotic  symptoms  from,  33  » 

extremely  toxic  action  of,  122 
intoxication,  cases  of,  34 
Koller's  demonstration  of,  22 
mixtures,  23 
substitutes,  23,  38,  41 
toxic  symptoms  of,  39 
toxicity  of,  39 

uncertainty  of  lethal  dose  of,  40 
Collapse,  102 

antidotes,  103 
precautions  against,  108 
Compact  bone,  distribution  of,  148 
Conductive  anesthesia,  178,  200 
definition  of,  22 
Halsted's  method,  22 
in  mandible,  technique  of,  219 
at  maxillary  tuberosity,  203,  227 
mountings  of  syringe  for,  183 
points  of  injection  in  maxilla,  182 
by  way  of  posterior  palatine  foramen, 

190 
principles  of,  228 
resume  of  clinical  value  of,  226 
Condyloid  process,  216 
Contra-indications  to  local  anesthesia,  102 
Coronoid  process,  143 


Coryza,  novocain  in,  129 

Crown    and   bridge    work,    indication    for   local 
anesthesia  in,  127 


Deciduous  teeth,  putrescent,  ethyl  chlorid  for, 

196 
Deglutition,  difficult,  due  to  faulty  technique,  224 

difficulties  in,  due  to  faulty  injection,  189 
Dental  nerves,  anterior  superior,  206 
posterior  superior,  204 
superior,  167 
Dentin,  anesthesia  of,  119 

hypersensitive,  quinin  and  morphin  in,  124 

injection  indicated  for  anesthesia  of,  122 

nerve  tendrils  in,  176 

sensitivity  of,  173 
Devitalizing  fiber,  indications  for,  126 

of  pulps,  arsenic  paste  in,  106 
Diabetes,  harmlessness  of  normal  solution  in,  109 
Diffusion,  details  of,  157 
Dioscorides,  early  attempts  at  local  anesthesia, 

21 
Disinfection  of  field  of  injection,  95 

of  mucosa,  95 
Dissolving  cups,  70 

Distilled  water,  importance  of  purity  of,  67 
Dolantin,  53 
Dolorant,  53 
Dosage  for  local  injection,  231 

of  novocain-suprarenin,  45,  61,  76 

tables  of,  233 


Ear,  referred  pain  in,  166 

Erotic  symptoms  due  to  cocain,  39 

Eroticism,  33,  39 

Ether  spray,  effects  of,  36 

Ethmoidal  nerve,  posterior,  158 

Ethyl  chlorid,  99 

effects  of,  36 

in  inflammatory  conditions,  195 
Eucain,  alpha  and  beta,  23,  38 
Eusemin,  toxicity  of,  41 

Extent  of  local  anesthesia  in  the  maxillae,  229 
Extirpation  of  pulps,  120 

painless,  126 
Extractions,  wound  treatment  following,  105 
Eye,  referred  stimuli  in,  167 


Facial  nerve,  162 
Fauces,  211 

Fissure,  infra-orbital,  203 
pterygoid,  214 


INDEX 


239 


Foramen,  anterior  palatine,  142 
incisive,  141 

injection  in,  contra-indicated,  190 
inferior  dental,  143 

injection  at,  208 
infra-orbital,  140,  206 
mandibular,  143 

injection  at,  208 
nerves  and  bloodvessels  at,  224 
mental,  141,  209 

injection  at,  212,  225 
ovale,  162 

posterior  palatine,  141,  170 
injection  at,  187 
Foramina  in  anterior  surface  of  maxilla,  140 

in  palatal  surface  of  maxilla,  142 
Fossa,    anterior   palatine,    injection   in,    contra- 
indicated,  190 
canine,  139 

injection  in,  206 
incisive,  137 
mental,  137 

injection  in,  192,  194 
retromolar,  143,  220 
Freezing  agents,  35 
Frontal  nerve,  158 


Ganglion,  ciliary,  158 
Gasserian,  158 
Meckel's,  160 
otic,  162 
semilunar,  158 
sphenopalatine,  160 
Gangrene  due  to  infection,  113 
Gasserian  ganglion,  158 

General  anesthesia  as  an  auxiliary  to  local,  97 
dangers  of,  25 
death  statistics  of,  26 
disadvantages  of,  29 
Gingival  nerves,  superior  anterior  and  posterior, 

166 
Gland,  large  mandibular,  162 

parotid,  163,  219 
Glossopharyngeal  nerve,  162 
Groove,  mylohyoid,  144 


H 


Hallucinations  due  to  cocain,  39 
sexual,  27 

Head  protection,  Witzel's,  119 

Healing,  process  of,  133 

following  dental  operations,  79 
novocain  in  modifying  the,  130 

Heart,  preliminary  examination  of,  32 

Hematoma,  203 

Hemolysis   produced    by   non-isotonic   prepara- 
tions, 53 


Hemorrhage,  postoperative,  106 
History  of  anesthesia,  21 
Holocain,  23,  38 
Hubs,  83 

Hydrogen  dioxid  and  novocain  mixture  contra- 
indicated,  71 
Hyoscin  in  postoperative  treatment,  106 
Hypalgesia,  etiology  of,  20 
Hyperalgesia,  etiology  of,  20 
Hypersensitive  dentin,  anesthesia  in,  120 
Hypertonic  solutions,  53 
Hysteria,  anesthesia  in,  131 
Hysterical  patients,  33 

spasms  following  novocain  injections,  116 


I 


Idiosyncrasy,  102 
Incisive  foramen,  142 

fossa,   137 
Incisors,  lower,  injection  for,  195 

upper,  injection  for,  180,  185,  188 
nerve  supply  of,  167 
Infection,  accidents  due  to,  104 

external  injection  in  case  of,  225 
Inferior  dental  foramen,  143 
nerve,  162 

topography  of,  210 
Infiltration  anesthesia,  definition  of,  25 
Schleich's,  36 

and  Reclus',  22 
mucous  anesthesia  by,  178 
Inflammation,  anesthesia  in  therapy  of,  129 

povocain  tamponade  in,  105 
Inflammatory  conditions,  anesthesia  in,  195 
Infra-orbital  foramen,  140 
injection,  206 

extent  of  anesthesia  following,  230 
nerve,  158,  165,  202,  204 
Infratrochlear  nerve,  158 
Injection  in  canine  fossa,  206 
conductive,  200 
diagram  illustrating  technique  and   dosage 

for,  231 
external,  in  case  of  ankylosis  and  infection, 

225 
factors  in  a  successful,  71 
infra-orbital,  206 
intra-osseous,  199 
labial,  183 

at  mental  foramen,  225 
in  mental  fossa,  192,  193 
in  mandible,  buccal,  191 

in  gingival  papillae,  193 
in  maxilla,  buccal,  183 

conductive  at  tuberosity,  182 
at  maxillary  tuberosity,  203,  227 
palatal,  186 
peridental,  197 
peripheral,  in  abscessed  areas,  196 


240 


INDEX 


Injection  for  several  upper  teeth,  184 

in  swollen  areas,  196 

tables  of,  233 

technique  of,  178 

waiting  periods  following,  229,  234 
Insanity,  anesthesia  in,  130 
Instrumentarium,  66,  80,  93 

glass  jar  for  preserving  syringes,  88,  92 
tray  for  syringes,  94 

hubs,  83 

needles,  83 

Riethmtiller's  modified,  91 

stock  flask  for  Ringer  solution,  66,  93 

syringe,  80 
Internal  genial  tubercles,  142 
Intoxication  from  novocain,  112 

absence  of,  117 
Intra-osseous  injection,  199 
lodin,  application  of,  96 

colorless  preparations  of,  96 
solutions  of,  96 

for  disinfection  of  field  of  operation,  95 

tincture  of,  effect  of,  95 
Iodoform  for  wound  treatment,  105 
Iridioplatinum  needles,  84 
Irritability,  combating  local,  131 
Isotonia,  52 


Jaws,  transverse  sections  of,  150 


K 


Roller's  demonstration  of  cocain,  22 
Krause's  world  anesthetic,  53 


Lacerations,  novocain  in  treatment  of,  130 
Lacrimal  nerve,  158 

secretion,  increase  due  to  anastomoses,  167 
Lactation,  novocain  in,  99 

Landmarks    for    mandibular    conductive    anes- 
thesia, 211,  220 
Lateral  incisors,  upper,  injection  for,  180,  182 
Ligament,  pterygomandibular,  217 
Lingual  nerve,  162,  164,  173,  202,  214 

distribution  of,  166 
Lingula,  217 

mandibular,  144 
Local  anesthesia,  advantages  of,  28,  75 
over  general,  25,  28,  74 
agents  for,  35 
dangers  of,  99 

duration  of  unduly  prolonged,  116 
indications  for,  118 
preliminary  measures  in,  30 
safety  of,  26,  79 


Local  anesthesia  in  surgery,  application  of,  73 
technique  of,  135 
anesthetics,  requirements,  54 
versus  general  anesthesics,  25,  118 


M 


Mandible,  anatomic  features  of,  209 
areas  of  nerve  supply  in,  172 
injection  in  gingival  papillee  in,  193 
inner  surface  of,  142 
landmarks  for  conductive  anesthesia  in,  211, 

■  220 
lingual  injections  in,  195 
molar  folds  in,  211 
mucous  anesthesia  in,  191,  193 
origins  and  insertions  of  muscles  in,  209 
sections  of,  154 
Mandibular  anesthesia,  technique  of,  219 
foramen,  143 

injection,  advantages  of,  226 
difficulties  in,  221 
effect  of,  224 

extent  of  anesthesia  following,  232 
position  of  syringe  in,  208 
right  and  left,  technique  of,  223 
technique  of,  147 
Mandibular  lingula,    144 

nerve,  158,  162,  163,  164,  172,  202,  210,  214 
Masseteric  nerve,  163 
Maxilla,  buccal  and  labial  injections,  183 

diagram  showing  method  of  injection,  180 
injection  in  several  upper  teeth,  184 
nature  of  bone  in,  135 
nerve  supply  of,  162 

of  palatal  surface  of,  170 
palatal  injection  in,  186 

surface  of,  141 
points  of  injection  in  mucous  and  conductive 

anesthesia,  182 
resection  of,  74 
sections  of,  154 
surfaces  of,  135 
topography  of,  201 
Maxillary  nerve,  158 

branches  of  distribution,  160 
tuberosity,  170 
Meckel's  ganglion,  160 
Medullary  anesthesia,  23 
Mental  foramen,  141 

injection  at,  212,  225 
fossa,  137 

injection  in,  192,  194 
nerve,  162,  163 
spines,  142 
Molar   and   molars,    conductive   anesthesia   for, 

folds  of  mucous  membrane  in  mandible,  211 
lower,  mucous  injection  for,  191 
upper,  first,  mucous  injection  for,  204 


INDEX 


241 


Molar,  upper,  injection  for,  182,  184 
nature  of  bone  in,  140 
nerve  supply  of,  167 
Moore,  James,  experiments  in  local  anesthesia,  22 
Morphin  for  postoperative  treatment,  105 
in  pulpitis  and  pericementitis,   106 
as  a  sedative,  97 

in  cavity  preparation,  125 
Mucosa,  injection  in,  180 
Mucous  anesthesia,  178 
definition  of,  25 
extent  of,  in  mandible.  230 
in  inflammatory  swelling,  195 
in  mandible,  191 

in  maxilla,  points  of  injection,  182 
principles  of,  197 
waiting  period  in,  197 
membrane  in  mandible,  211 
Muscle,  buccinator,  203 

external  pterygoid,  203 
internal  pterygoid,  214 
masseter,  219 
temporal,  214 
tensor  palati,  162 
tympani,  163 
Muscles,  masticatory,  nerve  supply  of,  162 
origins  and  insertions  in  mandible,  209 
pterygoid,  216,  218 
Mylohyoid  groove,  143 
nerve,  162,  173,  214 


N 


Nalicin,  53 

Narcotic  slumber  following  novocain  injections, 

no 
Nasal  nerve,  158 

Nasopalatine  nerve,  160,  165,  166,  170,  193 
Necrosis  due  to  infection,  113 
Needles,  82 

breaking  of,  loi 

in  conductive  mandibular  anesthesia,  point 
of  insertion  of,  221 

iridioplatinum,  84 

position  of,  in  mucous  anesthesia,  182 

protection  against  contamination  and  dull- 
ing, 93 

removal  of  broken,  loi 

steel,  83 

trocar,  85,  226 
Nephritis,  harmlessness  of  normal  solution  in,  109 
Nerve  or  nerves,  anastomoses  of,  164 

anterior  palatine,  164,  170 
superior  dental,  206 

auriculotemporal,  162 

buccal,  anesthesia  of,  225 

buccinator,  162,  172 

caroticotympanic,  162 

chorda  tympani,  162 

conductivity  of,  200 
10 


Nerve    or    nerves,    facial,    temporary    paralysis 
of,   117 
fibrils,  medullated,  173 
fifth,  distribution  of,  160 
frontal,  158 
glossopharyngeal,  162 
inferior  dental,  162 

topography  of,  210 
infra-orbital,  158,  165,  202,  204 
infratrochlear,  158 
internal  pterygoid,  162 
lacrimal,  158 
lingual,  162,  164,  173,  202,  214 

course  of,  162 

distribution  of,  166 
long  ciliary,  158 
mandibular,  158,  162,  163,  164,  172,  202,  214 

foramen,  224 

topography  of,  210 
masseteric,  162 
maxillary,  158,  202 

branches  of  distribution,  160 
mental,  162,  163 
minute  distribution  of,  in  alveolar  process, 

periosteum  and  pulp,  173 
mylohyoid,  162,  173,  214 
nasal,  158 

nasopalatine,   160,   165,   166,   170,   193 
ophthalmic,  158 
orbital,  158 
palatal,  course  of,  162 
palatine,  160 

anterior,  166 

large  and  small,  166 
posterior  ethmoidal,  158 

superior  dental,  204 
pterygoid,  162 

of  right  orbit  and  maxilla,  159 
small  superficial  petrosal,  162 
sphenopalatine,  158 
superior  dental,  158,  202 
course  of,  163 

gingival,  anterior  and  posterior,  166 

maxillary,  distribution  of,   163,   164 
supply  of  masticatory  apparatus,  157 
areas  of,  167 

of  maxilla,  162 

of  walls  of  bloodvessels,  177 
supra-orbital,  158 
supratrochlear,  158 
temporal,  162 
temporomalar,  158 
trigeminal,  157 

diagram  of  distribution  of,  161 

distribution  of,  168 
Vidian,  160 
Nirvanin,  23,  38 
Nitrous  oxid  and  oxygen  as  an  auxiliary  to  local 

anesthesia,  98,  99 
Non-isotonic   preparations,    hemolysis    produced 
by,  53 


242 


INDEX 


Novocain,  action  of,  44 
advantages  of,  42,  46 
dosage  of,  45,  61,  76 
effects  of,  45 

and  hydrogen   dioxid   mixture   contra-indi- 
cated, 71 
injections,  accidents  following,  no 
local  action  of,  100 
low  toxicity  of,  42 
maximal  dose  of,  78 
opinions  regarding,  46 
and  peptone  mixtures  contra-indicated,  71 
pharmacology  of,  44 
pluglets  for  pressure  anesthesia,  120 
powder,  syringe  for  spraying,  105 
and  its  solutions,  44 

Braun's  experiences  with,  72 
solution,  tablet  method  preferred,  59 
Novocain-suprarenin,  47 

and  sodium  chlorid,  compound  tablets 
contra-indicated,  71 
the  solution  of,  52 
solution,  addition  of  calcium  salts,  62 

composition  of,  66 

and  preparation,  61,  66 

decomposition  of,  70 

dissolving  cups  for,  70 

modification  of,  60,  70 

Ringer  base  preferable  to  physiologic 
salt  solution,  64 

sterilization  of,  69 

symptoms  of  decomposition  of,  52 

untoward  effect  of  alkalies  on,  57,  68 
systemic  effects  after  absorption  of,  45 
tablets,  57 

sterility  of,  57 
for  tamponing  inflamed  wounds,  105 
in  the  therapy  of  inflammation,  129 
toxic  action  of,  in 


O 


Oblique  lines,  208,  219 

external  and  internal,  143 
Odontoblastic  layer  in  dentin,  173 
Old  persons,  nature  of  bone  in,  138 
Ophthalmic  nerve,  158 
Orbital  nerve,  158 
Orthoform,  23,  38 

in  nasal  catarrh,  129 
Orthonal,  53 

Osseous  substance,  structure  of,  in  maxillge,  ii 
Otic  ganglion,  162 


Pacini's  corpuscles,  173 
Pain,  character  of,  19 
combating,  131 


Pain,  conduction  of,  20 

physiology  of,  18 

psychology  of,  17 
Painlessness,  duration  of,  133 
Palatal  injection  in  maxilla,  186 
Palate,  bony  surface  of,  188 

mucous  surface  of,  189 
Palatine  foramen,  posterior,  situation  of,  187 

nerve,  160 

anterior,  164,  166,  170 
large  and  small,  166 
Paralysis,  due  to  injection  of  alcohol,  118 

treatment  in  accidental,  116 
Parotid  gland,  163 

Patient,  preparation  of,  for  local  anesthesia,  96 
Peptones  and  novocain  mixture  contra-indicated, 

Pericementitis  in  anterior  teeth,  ethyl  chlorid  in, 

99 

morphin  in,  106 
Pericementum,  nerve  supply  of,  173 
Peridental  injection,  197 
Perineural  anesthesia,  definition  of,  22 
Periosteal  anesthesia,  179 

Periosteum,  minute  distribution  of  nerves  in,  173 
Peripheral  injection  in  abscessed  areas,  196 
Petrosal  nerve,  small  superficial,  162 
Phenyphrin, 53 
Pipette,  standard,  50 

Plexus,  sympathetic,  of  internal  carotid  artery, 
162 

tympanic,  162 
Pohl's  a-c  subcutaneous  tablets,  53 
Posterior  palatine  foramen,  141 
Postoperative  hemorrhage,  106 

pain,  103 

therapeutic  measures  in,  105 
aspirin,  105 
morphin,  105 
pyramidon,  105 
trigemin,  105 

treatment,  hyoscin-morphin  in,  106 
Potassium  sulpha/te,  addition  to  injecting  solu- 
tion, 65 

sulphocyanate    in    lesions    of    mouth    and 
tongue,  133  _ 
Pregnancy,  novocain  in,  99 
Preparation  of  patient  for  local  anesthesia,  96 
Pressure  anesthesia,  36,  120 
Process,  coronoid,  143 

zygomatic,  203 
Pterygoid  fissure,  214 

nerves,  162 

internal,  162 
Pterygomandibular  ligament,  217 

space,  214,  216 
Pulp,  anesthesia  of,  119 

devitalization,  arsenic  paste  for,  106 

exposure  of,  120 

extirpation,  126 

minute  distribution  of  nerves  in,  1 73 


INDEX 


243 


Pulp,  nerves  and  bloodvessels  in,  175 
Pulpitis,  morphin  in,  106 

Putrescent  deciduous  teeth,  ethyl  chlorid  for,  196 
Pyorrhea  alveolaris,  injection  in,  199 
injection  contra-indicated  in,  114 
Pyramidon  for  postoperative  treatment,  105 
Physiological  salt  solution,  65 


QuiNiN  as  a  sedative  in  cavity  preparation,  124 
and  urea  hydrochlorid  compounds  contra- 
indicated,  43 


R 


Ramus,  ascending,  143 

anatomic  features  of,  209 
Reclus'  infiltration  anesthesia,.  22 
Referred  pain,  166 
Reflex  pain,  166 

Regional  anesthesia,  definition  of,  22 
Renoform,  23 
Resection  of  maxilla,  74 
Retromolar  fossa,  143 

triangle,  220 
Richardson's  ether  spray,  22 
Ringer  solution,  62 

advantages  of,  64 

formula  of,  67 

sterilization  of,  67 

stock  flask  for,  66,  93 
Ritsert's  simplex  subcutin,  53 
Root  canal  filling,  126 

treatment,  126 

aqua  regia  in,  127 
Roots,  loose,  in  mandible,  injection  for,  193 


Sacral  anesthesia,  117 

Salt  solution,  addition  of  hydrochloric  acid  to,  58 

Schleich's  infiltration  anesthesia,  22 

Schroder's  analgesic,  53 

vScopolamin  as  a  sedative,  97 

slumber,  74,  75 
Sedatives,  bromural,  97 

camphorated  validol,  96 

effect  of,  133 

morphin,  97 

scopolamin,  97 

veronal,  97 
Selection  of  anesthetic,  principles  for,  44 
Semilunar  ganglion,  158 
Sensibility  of  various  tissues,  26 
Septa,  alveolar,  150 
Sexual  affections,  33,  39 

hallucinations,  27 


Shock,  102 

Soda,  precipitating  effect  on  novocain,  57 
Sodium  bicarbonate,  addition  to  injecting  solu- 
tion, 65,  78 

chlorid  and  novocain-suprarenin,  compound 
tablets  contra-indicated,  71 
solution,  65 
Solubility  of  local  anesthetics,  37 
Solution,  requirements  of,  54 

tablet  method  preferred,  59 

temperature  of,  54 
Sphenopalatine  ganglion,  160 

nerve,  158 
Spines,  mental,  142 
Spongiose  bone,  135 

distribution  of,  148 
Spongy  tissue,  injection  in,  185 
Stasis  bandage,  90 
Sterility  of  syringes,  89 
Sterilization  of  ampoules,  56,  90 

of  novocain-suprarenin  solution,  69 

of  Ringer  solution,  67 
Sterilizer,  electric  preferred,  68 
Stimuli  referred  by  anastomoses,  166 
Stock  flask  for  Ringer  solution,  66,  93 
Stovain,  23,  38 
Subcain,  53 
Subcutin,  23 

Suggestion,  mental,  in  local  anesthesia,  27 
Sulcus,  infra-orbital,  160 

mandibular,  143,  222 
Superior  dental  nerves,  158,  167 

course  of,  163 
Supra-orbital  nerve,  158 
Suprarenal  extract,  effects  of,  24 
Suprarenin,  action  of,  49 

addition  to  novocain,  58 

dosage  of,  51 

effects  of,  23,  47 

of  admixture  with  novocain,  47 

no  tissue  lesions  from,  50,  60 

stability  of,  48 

tablet  form  of,  49,  50 

toxicity  of,  48,  49 
Supratrochlear  nerve,  158 
Surgery,  application  of  local  anesthesia  in,  73 

oral,  118 
Swelling,    inflammatory,    mucous    injection    in, 

Swollen  areas,  injection  in,  196 
Syncope,  102 
Syringe,  80 

glass  jar  for  preserving,  88,  92 

tray  for,  94 
manipulation  of,  in  mucous  anesthesia,  180 
mountings  of,  in  conductive  anesthesia,  183 
for  infra-orbital  and  mandibular  injec- 
tion, 207 
in  mucous  anesthesia,  181 
sterilizer,  Bardct's,  89 
treatment  of,  88 


244 


INDEX 


Tablets,  novocain,  57 

Technique    of    injections,   diagram    illustrating, 
231 
tables  of,  233 
of  local  anesthesia,  135 
Temperature  of  solution,  54 
Temporal  nerve,  162 
Temporomalar  nerve,  158 
Tensor  palati  muscle,  162 
tympani  muscle,  163 
Third  person,  necessity  for  presence  of,  108 
Thymol,  addition  of,  54 

alcohol  for  disinfection  of  mucosa,  96 
Tomes'  fibrils,  176 
Tongue,  lingual  nerve  in,  164 
nerve  supply  of,  162 
novocain  in  injuries  of,  129 
Toxic  action  of  novocain,  iii 
Toxicity  of  local  anesthetics,  38 
Trigemin  for  postoperative  treatment,  105 
Trigeminal  nerve,  137 
Trocar  needles,  85,  226 
Tropacocain,  23,  38 
Tubercles,  internal  genial,  142 
Tuberosity,  maxillary,  170,  202,  203 

extent  of  anesthesia  following  injection 

at,  229 
injection  at,  203,  227 
point  of  injection  in  conductive  anes- 
thesia, 182 


U 

Udrenin,  53 

Upper  anterior  teeth,  points  of  injection  for,  180, 

182 
Urea  hydrochlorid  and  quinin  contra-indicated, 

43 


Validol,  camphorated,  in  collapse,  103 

in  excited  patients,  96 
Vater's  corpuscles,  173 
Veronal  as  a  sedative,  97 
Vidian  nerve,  160 

W 

Waiting  periods,  following  injections,  229,  234 

in  mucous  anesthesia,  197 
Wilson's  anesthetic,  53 
Winter's  anesthetique  local,  53 
Witte's  local  anesthetic,  53 
Wounds,  novocain  treatment  of,  105 


YOHIMBIN,  38 

Young  persons,  nature  of  bone  in, 


Zygomatic  process,  203 


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